Quality Account
2014/15
Excellence in specialist and community healthcare
1
1 ANNUAL REPORT
ANNUAL
2014/2015
REPORT 2014/2015
Quality Account
2
Statement on quality by
Miles Scott, chief executive
4
Priorities for improvement
21 Improving patient safety
29 Improving patient experience
35 Improving patient outcomes
42Performance
44 Annex 1: statements
from commissioners, local
Healthwatch organisations
and Overview and Scrutiny
Committees
54 Annex 2: statement of
directors’ responsibilities for
the quality report
55 Appendix A: participation in
national clinical audits and
national confidential enquiries
57 Appendix B: national clinical
audit actions undertaken
59 Appendix C: local clinical
audit actions undertaken
60 Appendix D: further details
of agreed CQUIN goals for
2014/15
QUALITY ACCOUNT
2
Statement on quality by Miles Scott,
chief executive
There is no single way to define quality, especially for such a large
organisation with such a wide spectrum of services and with more than one
million patient contacts every year.
However, what is clear is that both patients and the
organisations that scrutinise us think we are a strong
organisation and provide high quality services.
More than 90 per cent of our patients receiving care
across a range of settings have told the Department
of Health that they would recommend St George’s as
a place to receive treatment and be cared for through
the Friends and Family Test.
In the latest edition of the National Staff Survey our
staff are again ranked as being amongst the most
highly motivated in the country and in the highest
band for staff who feel proud of their trust and
would recommend that their friends and family
receive care there.
The Care Quality Commission declared that St
George’s was meeting every one of the essential
domains of care following their unannounced
inspection in February 2014. The CQC found the
overall standard of care we provide at all of our
sites to be ‘good’ and awarded the trust an overall
‘good’ rating, with some aspects of care rated as
‘outstanding’, confirming St George’s place as one of
the country’s leading teaching hospitals.
This level of recognition from the CQC provides
assurance that we offer high standards of clinical
services to our local community and beyond and that
we remain true to our values to provide excellence
across clinical care, education and research, which
ultimately means better care for all our patients.
Our Quality Account 2014/15 is full of examples of
high performance and commendable practice. We are
one of the few trusts in the country to have reported
lower than expected mortality rates every year since
publication started. Our mean level of performance
for ‘Harm Free Care’ was 94.47% for the period of
this report (April 2014 to March 2015) and was
slightly above the national average (93.79%) although
we did not achieve our internal target of 95%. Beneath
this high level figure there have been reductions in
the level of harm caused by pressure ulcers and falls.
Whilst the number of patients acquiring C.difficile
this year rose slightly, we were below our national
trajectory for this type of infection and St George’s
now has one of the lowest rates of C.difficile in
London. Last year we also further increased the
number of clinical audits we took part in.
We achieve these high levels because the culture at
St George’s is to always look at how we can improve.
There is a deep rooted desire running throughout the
organisation to always find ways to make things better
for our patients. Sometimes those improvements
are huge developments that are easily noticeable for
everybody, like our new helipad which has been in
operation for a year and is helping the most seriously
injured and ill people from across the south east of
England receive the expert life-saving care they need.
But sometimes they are the less obvious but equally
important changes, like improving our discharge
planning processes in the flow programme so that
patients are less likely to have to return to hospital for
further treatment after going home.
Since the last Quality Account, as well as the new
helipad, we have opened new facilities for patients
with the commissioning of Gordon-Smith ward
for oncology patients, additional facilities within
Amyand and Allingham wards, provided services
for the community at the Nelson Health Centre
and welcomed the First Touch Garden at the main
entrance of the St George’s Hospital.
During 2014/15 we continued to build on our
partnership with King’s Health Partners as joint
leaders of the new South London Collaboration for
Applied Health Research and Care (CLAHRC). The
CLAHRC pools the clinical and research expertise
of both the NHS and universities in south London,
and will make sure that patients benefit from
innovative new treatments and techniques that could
revolutionise future healthcare. We have also been
active participants in the Health Innovation Network
(South London). Continued investment in research
and our services at St George’s and Queen Mary’s
Hospitals and in the community is key to our plans for
the future of the trust. News that we were successful
in our bid to be part of the ‘100,000 genomes’
project was a great boost. This three-year programme
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ANNUAL REPORT 2014/2015
focuses on cancer and rare diseases and has the
potential to transform the future of healthcare.
We became a foundation trust in February 2015.
This achievement was the result of a long period
of improvement from a workforce whose energy,
commitment and compassion is outstanding. It also
demonstrates that we consistently live up to our
values; Excellent, Kind, Responsible and Respectful.
This becomes even more important now as our
accountability to our communities increases through
our council of governors.
Becoming a foundation trust means we can refocus
our efforts on our strategy and the development of
our services, to better meet the diverse and changing
needs of our patients in the future and keep them
at the heart of everything that we do. It also means
being able to make our own decisions about how we
invest in our sites and services.
Yours sincerely
Miles Scott Chief Executive
Dashboard: our priorities from
last year
Key
Achieved our aims and/or targets
Part achieved our aims and/or targets
Did not achieve our aims and/or targets
123 Page where more information can be found within the Quality Account available from St George’s Website
PRIORITY
Reduce grade three and four pressure ulcers
STATUS PAGE
110
London Quality Standards
112
Increase number of patients taking part in research projects
118
Participation in clinical audits
120
Use of CQUIN payment framework
122
Data quality
123
Maintain information governance toolkit band
124
Reducing medication errors
126
Reducing patient falls
127
Implement the national safety thermometer
128
Implement the early warning score indicator at HMP Wandsworth
129
Maintain lower than expected mortality rates
130
Assessing risk of VTE in admitted patients
131
Root cause analysis of VTE cases
131
Reducing rate of C.difficile infections
132
Patient safety incident reporting
133
Increase number of community learning disability referrals seen within four weeks of referral
134
Respond to 85 per cent complaints within 25 days
135
Increase the return rate for Friends and Family Test
137
Increase the number of patients who would recommend us to friends and family
137
Increase sexual health support in Wandsworth secondary schools
Improve participation rates for patient reported outcome measures
140
141
Reduce hospital readmissions
145
Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers
Never events
Reducing rate of MRSA infections
147
148
148
QUALITY ACCOUNT
4
Priorities for improvement in
2015/2016
In 2013/14 we agreed a new quality improvement strategy which centres
on the three essential domains of patient safety, experience and outcomes.
For 2015/16 we have refreshed this strategy and
agreed six new commitments against each domain
which illustrate how we will achieve improvements.
These priorities have been determined through
a review of activity during 2014/15 and through
engagement with key stakeholders. In addition, we
have committed to build and strengthen existing work
programmes recognising that a 12 month period may
not be sufficient to fully embed sustainable changes.
•we will ensure that our patients are cared for in a
clean, safe and comfortable environment through
use of the clinical audit programme and ensuring
that findings are acted upon
•we will ensure that our most vulnerable patients
and service users are listened to and protected
from harm through introduction of the dementia
and delirium team and monitoring of the clinical
care for individual patients.
The priorities indicated below are reflected in
the quality improvement strategy annual plan for
2015/16 and each element has agreed outcomes
with a nominated person accountable lead for
delivery against the priorities.
Improving patient outcomes
Improving patient safety
•we will create reliable processes to reduce avoidable
harm. Examples of outcome measures: audit of
practice against the WHO safer surgery checklist,
ward level data eg heatmap/safety thermometer to
support management action at the front line
•we will establish strong multidisciplinary teams who
communicate clearly across boundaries through
development forums for clinical governance leads
•we will give timely and relevant feedback to teams to
enable staff to be knowledgeable about patient safety
•we will promote a culture of zero tolerance
through challenging unsafe practice
•we will promote an open and transparent culture
where we listen and act on staff concerns through the
Safety Forum initiative, and ongoing development/
monitoring in relation to the Duty of Candour
•we will encourage the involvement of patients in
patient safety initiatives through the roll out of
the patient safety booklet/films.
•we will evaluate clinical audit results and act
on findings to ensure audit contributes to
improvements for patients
•we will support staff to improve outcomes by
provision of training and expert support
•we will communicate outcomes, promoting shared
learning and prioritisation of improvement projects
•we will evidence that we are clinically effective
and implementing evidence based best practice
•we will fully participate in national clinical audits
and use results to improve local practice
•we will aspire to achieve best practice across
all clinical areas so that patients have the best
possible outcome.
Our four clinical divisions have each taken these
commitments and translated them into quality
improvement plans specific to their patients and
services. The implementation of these plans will be
overseen by our Quality and Risk Committee, which
is responsible for monitoring quality at the trust.
Improving patient experience
We will be reporting on our performance against
our quality improvement strategy at our (held in
public) board meetings throughout 2015/16. Our
performance will also be reported on our website:
www.stgeorges.nhs.uk
•we will listen to and involve people who use
our services through further improvement
work in relation to the complaints function and
monitoring of key metrics
•we will use feedback as a vehicle for continuous
improvement adopting best practice where
possible through triangulation
Looking forward, there are a number of additional
quality priorities that the organisation will need
to implement during 2015, such as the outcome
of the NHS England review of maternity services,
which is expected to recommend choice for
maternity care; plus the expected revised national
cancer strategy.
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ANNUAL REPORT 2014/2015
The table below indicates progress that has been made against the
priorities since the publication of the 2013/14 Quality Account:
IMPROVEMENT PRIORITY FOR 2014/15 PROGRESS AS OF MARCH 2015
Conduct twice yearly nursing and midwifery •Establishment review completed in May, recommendations agreed by the
reviews as recommended in the National
board with all bar one implemented during 2014/15
Quality Board report ‘how to ensure the
•Further acuity/dependency review undertaken in autumn of 2014
right people, with the right skills, are in the
•Safe staffing framework in place and amended to include ‘Red flag’ indicators
right place at the right time.’
•Monthly reporting to board in place regarding safe staffing
•Nursing/midwifery workforce programme in place since August 2014 to
support the forward planning for recruitment and retention of staff and
the commissioning of additional operational capacity during the year.
To ensure that we implement the
recommendations of the Clwyd/Hart
review of the complaints system in
hospitals to further strengthen our
response to patient complaints, learn
from their feedback and use as a means
to implement improvements.
•Work undertaken to strengthen the complaints function including
performance management for response time and to ensure evidence of
learning from complaints
•Participation in national patient surveys for inpatient, maternity and
paediatric settings. Final results awaited for some surveys and work to
focus on response to findings
•National cancer patient survey results received indicating that St George’s
was one of the 10 most improved trusts. Responses to findings now
agreed and being implemented
•Annual community patient survey (Sept 2014) outcomes reviewed with
action plans at DGB
•Strengthening of use of Family Friendly Test (FFT) now in place across
inpatient, emergency department (ED), midwifery settings. A trial of the
medication safety thermometer also completed. Focus on triangulation of
commentary with complaints/compliments data. FFT feedback and data
being displayed, actions taken. Emergency Department have marked uptake
in responses using SMS service.
To ensure that we meet the ‘Duty of
•Report produced to identify current practice and challenges. Monthly
Candour’ requirements and make sure we
reports being collated to indicate compliance with Duty of Candour
continue to endorse and develop a culture •Master classes held to raise awareness with senior clinicians and support
of openness and transparency.
good practice with patients.
To ensure we focus on improving the
experience of patients visiting our
outpatient departments.
•Roll out of E-triage began February 2015
•Capacity and demand analysis completed across specialities
•Refurbishment of estate to commence April 2015 including improved
signage and new furniture installed in clinic rooms
•Patient experience training delivered to call centre and clinic
administrative staff March 2015, training opportunities advertised to staff
•Successful recruitment of permanent staff, ongoing staff forums. Roll out
of FFT in April 2015.
To continue to focus on reducing
•Patients admitted with sepsis from the ED are regularly audited to identify
avoidable grade 3 and 4 pressure ulcers,
MISSED (Mortality In Severe Sepsis in the ED) this is reported at the
implementing the Sepsis Care Bundle to
sepsis group
improve care of patients with severe sepsis •The trend for grade 3 and 4 pressure ulcers is showing a downward trajectory.
and improving our discharge process.
To maintain our commitment to improving
end of life care.
•Programme board established with agreed scope to take forward trustwide actions to implement NICE standards and five priorities (which
replaced the Liverpool Care Pathway)
•Audit of palliative care activity completed during the year with presentation
to key committees
•Development of new care plan for patients.
To establish the dementia and delirium team •Full nursing team recruited and have to date met all CQUIN targets for
to meet the national CQUIN requirements,
2014/15
embed the ‘butterfly’ scheme and improve
•Dementia and delirium guidelines updated
the care of this vulnerable group of patients.
•Dementia training roll out.
QUALITY ACCOUNT
6
Developing the Quality Account
All NHS trusts report the same information which
allows us to benchmark our performance against
other trusts. This is important for not only letting
us know how we are doing, but means that trusts
with similar services can learn from each other.
The Department of Health (DH) and Monitor
produce guidance on what should be reported
in the Quality Account for NHS trusts and NHS
foundation trusts.
As St George’s achieved foundation trust status
mid-year 2014/2015 we must comply with both
Monitor’s reporting requirements and those set
by DH. This year’s Quality Account relates to the
quality of our services across the entire year,
including the time when they were provided by St
George’s Healthcare NHS Trust. Monitor requires
us to produce an annual Quality Report which
includes all of the reporting requirements of the
Quality Account plus some additional requirements
they have set.
Every NHS trust in the country has to report
against the mandatory indicators listed below:
•Mortality rates
•Patient reported outcome measures (PROMS)
•Emergency readmissions
•Responsiveness to patients’ needs
•Friends and family test for staff
•Venous thromboembolism rates (VTE)
•C.difficile rates
•Patient safety incidents
To meet both DH and Monitor’s quality reporting
requirements we have consolidated all the quality
information into one document – the Quality
Report, but for reporting purposes to DH we will
call the Quality Report the ‘Quality Account’.
Monitor requires the trust to report on nine
voluntary indicators that reflect how we are
improving patient experience, patient outcomes
and patient experience. We have reported on ten
this year in a bid to better reflect the services we
provide and the patients we care for.
We have worked with local stakeholders to identify
which indicators to include in this year’s Quality
Account to make sure that the areas that matter
most to the people who use and provide our
services are covered. These stakeholders included
our staff, our council of governors, patients,
local Clinical Commissioning Groups (CCGs),
Wandsworth Healthwatch and Wandsworth Council.
The voluntary indicators we have chosen to
include fit into the three essential domains of
our quality improvement strategy – improving
patient safety, improving patient experience and
improving patient outcomes. In this year’s Quality
Account, we continue with the same indicators as
last year to ensure continuity, comparability and
a clear narrative for readers to follow and have
selected additional indicators; ‘end of life care’
under ‘improving patient experience’ and ‘clinical
records’ under ‘improving patient outcomes’. We
will measure our performance against these in
next year’s Quality Account (2015/16).
Improving patient safety voluntary indicators:
•Medication errors
•Patient falls
•Patient safety thermometer
•Offender healthcare
Improving patient experience voluntary
indicators:
•Community learning disability referrals
•Complaints
•End of life care (new for 2015/16)
Improving patient outcomes voluntary
indicators:
•Sexual health in secondary schools
•Clinical outcome measures in community
services
•Clinical records (new for 2015/16)
The draft Quality Account has been shared with
stakeholders both for assurance and to increase
understanding of the value of the report and how
we record the data for each indicator. This Quality
Account has been reviewed by:
•St George’s Quality and Risk Committee
•St George’s Audit Committee
•St George’s Executive Management Team
•St George’s Board
•St George’s Patient Reference Group
•Wandsworth Healthwatch
•Merton Healthwatch
•Lambeth Healthwatch
•Wandsworth CCG
•Wandsworth Council Adult Care and Health
Overview and Scrutiny Committee
7
ANNUAL REPORT 2014/2015
Sharing a draft version of the report with our
stakeholders has given them the opportunity to
provide feedback on our performance in a formal
statement. These statements are published in
Annex 1.
To put our performance into context we have
compared our performance for all of the indicators
in this report against our own performance over
the last two years, and where possible and
relevant, against the national average performance
as published on the Health & Social Care
Information Centre www.hscic.gov.uk
Testing
It is a requirement that our auditors test certain
indicators to provide assurances that there is a
robust audit trail.
•One indicator is mandatory. This is referral to
treatment times (RTT)
•One indicator needs to be selected by the Trust.
For 2014/15 we have chosen ‘emergency
readmissions within 28 days of discharge’.
•One local indicator needs to be selected by the
trust’s council of governors. For 2014/15 they
have chosen ‘clinical outcome measures in
community services’. Within the process for this
area, sufficient data was not available for audit.
London Quality Standards
Why is this important?
How are we doing?
Many patients are admitted to hospital as
emergencies and the treatment they receive
in the first hours and days in hospital is very
important. The London Quality Standards (LQS)
were developed in 2011 after a review found
variable, and often inadequate, involvement of
consultants in the assessment and management
of acutely ill patients in London. It was estimated
that improved care would save 500 lives each year
across the city. The standards specify the optimal
way to manage patients in the crucial early period
after admission. There are different standards
appropriate for different groups of patients.
In total St George’s met 123 of the 177 standards
in full. Most others were met in part. The main
challenges we need to overcome are of two types.
The first is that sometimes we are delivering what
is required but not as quickly as we would like to.
The second is where we are delivering the standard
most of the time but not every hour of every day.
As part of the south west London five year strategic
plan, St George’s agreed to progress towards
meeting the full range of the LQS by the end of
2016/17. In November 2014 we participated in a
Peer Review Audit with the other acute providers in
south west London. This covered the full range of
LQS except for maternity. http://www.swlccgs.nhs.
uk/2015/03/south-west-london-urgent-emergencycare-peer-review-visit-report/
The audit methodology meant that to be scored
green the trust had to fully meet the standard.
Where the standard was not met, or was met
in part it was scored red. Where there was
insufficient evidence for the peer assessors to
make a decision it was scored amber. As the
standards and methodology have changed it is not
possible to undertake a direct comparison with
previous internal assessments.
RED: NOT
AMBER:
GREEN:
FULLY MET INSUFFICIENT
MET
EVIDENCE
Adult acute
medicine
(22 standards)
7
1
14
Adult emergency
general surgery
(26 standards)
7
7
12
Emergency
department
(14 standards)
3
0
11
Critical care
(26 standards)
4
0
22
Fractured neck
of femur pathway
(13 standards)
2
0
11
Paediatric acute
medicine
(22 standards)
6
1
13
Paediatric surgery
(23 standards)
5
1
17
Urgent care
centre
(31 standards)
8
0
23
QUALITY ACCOUNT
What are our aims?
Our aim is to continue to work towards meeting
the standards by 2016/17. One of the challenges
is the availability of key staff. We are working
with the other acute trusts in south west London
(Croydon, Epsom and St Helier, Kingston) to
identify areas where working together is beneficial.
Learning from other organisations
At St George’s we are committed to learning from
other organisations to see how we can apply best
practice from high performing services elsewhere
for the benefit of our patients.
As well as learning from best practice we have
a duty to learn from other organisations where
serious mistakes have been made and serious failing
uncovered. It is vital that we understand what went
wrong at these organisations so that we can make
sure that we are doing all that we can to minimise the
risk of the same things happening at St George’s.
We have strong governance and audit processes
that help us react quickly and decisively to emerging
reports, guidance, inquiries and recommendations.
As well as reviewing the integrity of our financial
accounts, our audit committee (which is made up of
non-executive directors) reviews and independently
scrutinise the trust’s systems of clinical
governance, internal control and risk management.
This ensures through proper processes and
challenges that integrated governance principles
are embedded and practised across all St George’s
activities and that they support the achievement of
the trust’s objectives.
The audit committee ensures that the work of
its own internal auditors, clinical auditors and
external auditors is aligned. The audit committee
reviews the work and findings of the external
auditors and considers the implications and
the trusts responses, and makes sure that the
responsibility and accountability for developing and
implementing and necessary actions sits at board
and senior clinical level.
Below is a brief summary of how we have continued
to react to some high profile inquiries and reports.
As part of our commitment to transparency and
to increase patient confidence in our services we
publish our reaction to high profile inquiries and
reports on our website and discuss them in board
meetings which are open to all members of the
public. These papers and details of our board
meetings are available at www.stgeorges.nhs.uk/
about/board/board-meetings/
8
Mid Staffordshire NHS Foundation Trust
public review
The inquiry was chaired by Sir Robert Francis QC
whose report made 290 recommendations to the
Secretary of State for Health.
The board held strategy sessions during 2013/14
and following the agreement to the seven
commitments below has monitored progress
against individual elements of those commitments
during 2014/15.
The trust board committed to:
•ensure that quality is maintained as the board’s
top priority
•to strengthen clinical leadership including
medical and nursing
•to embed and live the trust’s values
•to ensure that there is a clear approach to the
identification of a single lead consultant in
multidisciplinary care
•to ensure the constant improvement in the
quality of care
•to devolve the boards commitment to quality at
every level though the organisation
•to meet the trust’s responsibilities under the duty
of candour.
The trust has also during 2014/15 continued to
review progress against a number of key reports
considered in the previous year:
•The Keogh mortality review
•Berwick review into patient safety, ‘A promise to
learn, a commitment to act: improving the safety
of patients in England’
•The Clywd-Hart Report – ‘Putting patients back
into the picture’
•The Cavendish review of healthcare assistants
and support workers in the NHS and social care.
Monitoring has been undertaken through the patient
safety, patient experience, quality and risk and
workforce committees with oversight by the board.
The trust has received the Kate Lampard QC
report which was a ‘lessons learned’ report
drawing on the findings from all of the published
investigations into Jimmy Savile and the
subsequent allegations into wrongdoing at NHS
organisations. The trust is currently considering
this report, the recommendations and implications
for the trust will be considered in Q1 of 2015/16.
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ANNUAL REPORT 2014/2015
Review of services
St George’s is the largest healthcare provider in south west London, and
one of the largest in the country. St George’s serves a population of 1.3
million people across south west London. A large number of services,
like cardiothoracic medicine and surgery, neurosciences and renal
transplantation, also cover significant populations from Surrey and Sussex,
totalling around 3.5 million people.
Most of the services are provided at St George’s
Hospital in Tooting, but we also provide many
services from Queen Mary’s Hospital in
Roehampton, health centres across Wandsworth,
Wandsworth Prison and from GP surgeries,
schools, nurseries and in patients’ own homes.
We also provide care for patients from a larger
catchment area in south east England for specialist
services like complex pelvic trauma. Other services
treat patients from all over the country like family
HIV care, bone marrow transplantation for noncancer diseases and penile cancer.
A number of our services are members of
established clinical networks which bring together
doctors, nurses and other clinicians from a range
of healthcare providers working to improve clinical
outcomes and patient experience. These networks
include the South London Cardiac and Stroke
Network and the South West London and Surrey
Trauma Network, for which St George’s Hospital
is the designated heart attack centre, hyper-acute
stroke unit and major trauma centre.
During 2014/15 we provided and/or sub-contracted
54 NHS services. We have reviewed all the data
available on the quality of care in all of these
NHS services.
The income generated by the NHS services
reviewed in 2014/15 represents 100 per cent of
the total income generated from the provision of
NHS services by St George’s University Hospitals
NHS Foundation Trust for 2014/15.
The services we provide can be categorised as:
•National specialist centre
We provide specialist care to patients from
across the country for complex pelvic trauma,
family HIV care, lymphoedema and penile cancer.
•Tertiary care
We provide tertiary care like cancer services,
neurosciences and renal services for the six
boroughs of south west London and the counties
of Surrey, Sussex and Hampshire.
We also provide specialist children’s cancer
services in partnership with The Royal Marsden
NHS Foundation Trust.
•Local acute services
We provide a range of local acute services
like A&E, maternity and general surgery to the
people of Wandsworth, Merton, and Lambeth.
•Community services
We provide a full range of community services to
the people of Wandsworth, making sure people
can manage their health better by accessing the
services they need closer to where they live and
work and in their own homes.
Our clinical divisions
Our services are split into four clinical divisions,
which all have their own clinically led divisional
management boards. Each board has a divisional
chair who is an experienced clinician, providing
expert clinical leadership to the staff of each
service so that the needs of the patients who
use them are best met. Every division has a
divisional director of nursing and governance who
is responsible for nursing, patient experience and
making sure that there are strong governance
structures within their division for improving the
quality of their services and safeguarding high
standards of care. Each division also has a
divisional director of operations who is responsible
for managing the operational, business and
logistical aspects of providing healthcare services.
The divisional boards are made up of the clinical
directors and heads of nursing who are responsible
for the specialist services within their division.
Surgery, theatre, neurosciences and
cancer division
Surgery and trauma clinical directorate
•Trauma and orthopaedics
•Ear, nose and throat
•Maxillofacial
QUALITY ACCOUNT
•Plastic surgery
•Urology
•General surgery
•Dentistry
•Audiology
Theatres and anaesthetics clinical directorate
•Theatres and decontamination
•Anaesthetics and acute pain
•Resuscitation
Neurosciences clinical directorate
•Neurosurgery and neuroradiology
•Neurology
•Neurophysiology
•Neurorehabilitation
•Pain clinic
Cancer clinical directorate
•Cancer
Medicine and cardiovascular division
Emergency and acute medicine
•Emergency department
•Acute medicine and senior health
Specialist medicine
•Lymphoedema
•Infection department
•Rheumatology
•Diabetes and endocrinology
•Chest medicine
•Endoscopy and gastroenterology
•Dermatology
Renal, haematology and oncology clinical directorate
•Renal transplantation
•Renal
•Medical oncology
•Clinical haematology
•Palliative care
10
Cardiovascular clinical directorate
•Cardiology
•Cardiac surgery
•Vascular surgery
•Blood pressure unit
•Thoracic surgery
Community services
Community Adult and Children’s directorate
Community Adult Health services
•Community nursing and community wards
•Intermediate care services
•Older people and neuro-therapies
•Day hospitals
•Specialist nursing
•Community learning disabilities
•Elderly rehabilitation in patient wards
Children and family services
•School and special school nursing
•Children’s continuing care
•Health visiting
•Child safeguarding team
•Children’s therapies and immunisation
•Homeless, refugees and asylum seeker team
Adult and diagnostic services
•Outpatient services
•Minor Injuries Unit
•Diagnostics
•Specialist rehabilitation
•Adult therapies – physiotherapy, dietetics
and podiatry
•Integrated sexual health
Offender healthcare
•Primary care
•Substance misuse
•Inpatient care
11
ANNUAL REPORT 2014/2015
Where our services are based?
Hospitals
We provide healthcare services at:
St George’s Hospital, Queen Mary’s Hospital
Therapy centres
•St John’s Therapy Centre
Health centres
•Balham Health Centre
•Bridge Lane Health Centre
•Brocklebank Health Centre
•Doddington Health Centre
•Eileen Lecky Clinic
•Joan Bicknell Centre
•Stormont Health Centre
•Tooting Health Clinic
•Tudor Lodge Health Centre
•Westmoor Community Clinic
•Nelson Health Centre
Prisons
•HMP Wandsworth
Community
We also provide services in GP surgeries, schools,
nurseries, community centres and in patients’
own homes.
Find out more about our services and the
clinicians and healthcare professionals who
provide them on the services section of our
website www.stgeorges.nhs.uk/services
Staff friends and family test (FFT)
Staff who would recommend the trust as a place to receive treatment to friends or family
Why is this important?
One of the trust’s strategic aims is to be an
exemplary employer. To achieve this we must
commit time, resources and effort into supporting
our staff and making St George’s both a great place
to receive healthcare and a great place to work. Our
staff are core to our success and are well-placed to
judge the quality of care we provide to our patients.
How did we do?
In the National NHS Staff Survey staff are asked
to state whether If a friend or relative needed
treatment I would be happy with the standard of
care provided by my organisation.
In the 2014 National NHS staff survey, 73 per
cent of our staff said that they agreed with this
statement. This is higher than the national
average (median) for acute trusts of 65 per cent
and higher than last year when 68 per cent of staff
said that they agreed with this statement.
Staff recommendation of the trust as a
place to work or receive treatment
As well as giving an individual score for each
question, a score is calculated for a number of key
indicators based on the answers to the questions
grouped under each indicator. One of these key
indicators is staff recommendation of the trust as
a place to work or receive care.
On a scale of 1-5, with 5 being the most positive, St
George’s scored 3.78 compared to 3.67 nationally
for acute trusts. Last year our score was 3.73.
This key indicator gives us a top ranking score, for
which we compare favourably with other acute trusts
in England. This also means that we have maintained
our status as one of the top 20 per cent of trusts in
the country for staff who would recommend the trust
as a place to work or receive treatment.
YEAR
STAFF WHO WOULD RECOMMEND ST
GEORGE’S AS A PLACE TO WORK OR
RECEIVE TREATMENT
(1 BEING POOR, 5 BEING EXCELLENT)
2014/15
3.78
2013/14
3.73
2012/13
3.68
National average
for acute trusts
(2014/15)
3.67
Friends and family staff survey
A new requirement in 2014 was to conduct the
friends and family test with our own workforce.
QUALITY ACCOUNT
In quarters one, two and four we gave staff
the opportunity to complete the survey, which
comprises two questions:
How likely are you to recommend this organisation to
friends or family if they needed care or treatment?
How likely are you to recommend this organisation
to friends or family as a place to work?
Our scores, by quarter, are listed here:
WOULD RECOMMEND
FOR TREATMENT
WOULD RECOMMEND
AS A PLACE TO WORK
Q1
81%
58.5%
Q2
80%
57%
Q4
81%
59%
Our aims
Our workforce is vital to the delivery of the highest
quality clinical services, education and research,
and will need to evolve to meet future needs. We
need to value our staff and ensure they champion
the trust’s values. Patients have commented that
happy staff result in happy patients.
We aim to further improve our score in the staff
recommendation of the trust as a place to work
or receive care indicator in the National NHS staff
survey and maintain our status as one of the
top 20 per cent of trusts in the country. We aim
to further improve our scores in the Friends and
Family staff survey in 2015.
Our 2015/16 workforce strategy action plan sets
out a programme of work that will support the
trust to respond to the issues raise in the staff
survey. These include:
Confidence to raise concerns
The trust is in the top 20 per cent for staff
agreeing that they would feel secure about raising
concerns about unsafe clinical practice. This is
a new question and in the context of the recent
national ‘Speak up review’ likely to be seen as a
key indicator. However, this contrasts with ratings
in the worse than average category for members
of staff witnessing and reporting potentially
harmful errors or incidents.
Tackling poor behaviour and bullying
Trust performance has remained steady with 31
per cent of staff saying that they have experienced
harassment, bullying or abuse from staff in the
past 12 months. The strategy to tackle bullying
includes coaching and training for managers
dealing with difficult staffing issues, tracking
and following up the range of concerns that
were raised in the CQC inspection in 2014 and
12
elsewhere, a poster campaign, the development of
a service providing listening for members of staff
and an opportunity to raise concerns, the bullying
and harassment support line, which is run by the
staff support service.
Discrimination
The trust position has remained the same
with regard to members of staff reporting
discrimination. Of greatest concern is that 38 per
cent of black and minority members of staff report
discrimination as compared to 14 per cent of white
members of staff. It is of further concern that 34
per cent of black and minority members of staff
report experiencing harassment, bullying or abuse
from members of staff in the last 12 months as
compared to 29 per cent of white members of
staff. St George’s is establishing a ‘St George’s as
One’ inclusion programme in 2015.
Our workforce strategy explains how we aim to
maximise the wellbeing of our staff and their
levels of contribution and engagement. You can
read the workforce strategy at www.stgeorges.nhs.
uk/about/our-strategy/strategies
Listening into Action
We recognise that as well as listening to our
patients, it is also important that we listen to our
staff and involve them when we try to identify
where improvements could and should be made.
That’s why we are fully on board with the national
Listening into Action staff engagement programme.
Listening into Action launched at St George’s in
March 2013. It is our way of working with and
engaging staff at St George’s. It’s about achieving
a fundamental shift in the way we work and
lead, putting clinicians and staff at the centre of
change for the benefit of our patients, our staff
and the trust as a whole. In the process, Listening
into Action is adopted and spread as a way of
sustaining continuous improvement.
Essentially, Listening into Action is about:
•engaging all the right people around delivering better
outcomes for our patients, our staff and our trust
•aligning ideas, effort and expertise behind the
patient experience, safety and quality of care
•overcoming widespread challenges around staff
engagement and morale
•developing confidence and capability of our
leaders to ‘lead through engagement’
collaborating across the usual boundaries, and
•engendering a sense of collective ownership
and pride.
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ANNUAL REPORT 2014/2015
Listening into Action complements other important
projects taking place at the trust, and the change
methodologies, systems and experience staff
develop and gain through this programme is in
many cases used to help achieve changes which
are identified by Listening into Action.
We have held Big Conversations in 2013 and
2014. Staff from all departments, levels and
roles came together and talked openly about
what matters to them, and what changes should
be prioritised. We use the feedback from these
events to inform our future actions and to support
and enable our teams to do the very best for our
patients and their families, in a way that makes us
proud of our work.
Research
Why is it important?
At St George’s, we are committed to innovating
and improving the healthcare we offer and a key
way we do this is by participating in research. Our
clinical staff keep abreast of the latest treatment
developments and through clinical trials, patients
are offered new drugs and devices and better clinical
care evolves. The key reason for our participation
in clinical research is to develop new and improved
clinical treatments for our patients and to realise
better ways to manage illness, thereby ultimately
improving the health of our local community.
St George’s is a collaborating site with Genomics
England for the ‘100,000 Genomes Project’.
Initially the focus will be on rare disease, cancer
and infectious disease. The project will allow
researchers to work together to build and share
new knowledge about the influence of genes on
health and disease that may be translated into
new diagnostic and treatment options for patients.
St George’s, in its partnership with St George’s,
University of London, aims to bring new ideas
and solutions into clinical practice. Clinical teams
are collaborating with scientists to investigate
the causes of range of diseases, to develop
better ways of diagnosis and tailored treatments.
St George’s has been heavily involved in the
development of new vaccines, on potential new
treatments for vascular dementia and on better
diagnostic for a range of infectious pathogens.
This highlights the importance of the relationship
with the university to improve both academic
knowledge and clinical practice.
We also want to thank the local community for
participating in research. Patients who participate
in research may derive an individual benefit
from, for example, new treatment opportunities.
However, support has been much wider with
sometimes less clear individual benefits. In this
last year, nearly 1,600 healthy teenage volunteers
in our local schools have given throat swabs
and information about themselves to help us
understand meningococcal infection, one of the
leading causes of meningitis. Our GP healthcare
partners have also offered great support,
discussing trial opportunities with and giving
information to patients.
Our strong relationship with the pharmaceutical
industry enables our clinical staff to keep abreast
of the latest developments and our patients to
have access to the newest treatments within
clinical trials. This includes access to new drug
treatment in a range of cancers, hepatitis B and
C, epilepsy, cardiovascular disease, Parkinson’s
disease, Meniere’s disease, multiple sclerosis,
Crohn’s disease, ulcerative colitis and stroke.
In 2014, the trust invested funds to allow
clinicians (doctors, nurses and other health
professionals) to have time away from clinical
duties to develop their research ideas into
research protocols. With clinical duties covered
by colleagues, these individuals are able to focus
for a short period of time (generally six months)
to develop new ideas and treatments for patients
at St George’s. To be successful, these proposals
will be externally reviewed and we hope will be
funded by research-grant awarding bodies.
Our outcomes
I. Participation:
One of the key ways of offering new treatments
is through participation in clinical trials that are
approved by the National Institute for Health
Research (NIHR), which supports NHS and
academic institutions to deliver quality research
that is patient-focused and relevant to the
NHS. These studies are adopted onto the NIHR
portfolio. In the calendar year 2014, there were
194 NIHR adopted trials open and recruiting in St
QUALITY ACCOUNT
George’s, with 9,021 patients taking part. This
was an increase from the 2013 where 3,994
patients took part in 182 research trials.
This is an astonishing increase but is down to
several unusual trials that are looking at new
diagnostic techniques and require many samples
to check the outcomes. We would hope to
continue to improve, but may not be able to meet
this level next year.
The number of patients receiving relevant health
services provided or sub-contracted by St George’s
in 2014/15 that were recruited during that period
to participate in research approved by the National
Institute of Health Research (NIHR) is 10, 574.
II. Approvals:
In 2014, the research office approved 187 new
studies to be performed at St George’s, an
increase from 164 in 2013. These range from
clinical trials of medicinal products (new drugs)
and medical devices, through to service and
patient satisfaction studies. Around 60% of these
are adopted on the NIHR portfolio, up from 30%
in 2013. Non-adopted studies include ‘Proof of
Concept’ studies, in which our researchers and
clinicians are gathering evidence that may develop
into larger adopted trials, student studies and
trials sponsored by commercial companies.
The approval time targets changed in April 2014.
Previously, studies were expected to be approved
within 30 days, but since April, we are now expected
to approve within 15 days. Before April, 88% were
approved within 30 days, but there has been a drop
since April in the 15 day target, to 62%. Overall, we
have approved 69% in the given timeline.
This is a focus for improvement in 2015.
III. Trials starting recruitment
In our most complex trials, we endeavour to get
the study approved and the first patients recruited
within 70 days of submission to the research office.
This is a new national metric and we have seen a
steady improvement in 2014 from 40.3% in Dec
2013 to 76.1% of trials up to September 2014,
and we are hoping to achieve 80% when the NIHR
publishes the figure for all trial approved in 2014.
We intend to continue improving this measure
through 2015.
IV. Ensuring compliance with ‘Good Clinical
Practice1’ guidelines for research
All trials require one institution or company to have
the legal responsibility to ensure that the trial is
run safely and gathers good quality information in
order to answer the research question e.g. does a
new drug lead to better outcomes compared to the
standard treatment? When we are the responsible
institution (sponsor) all our trials are closely
monitored by a team from the research office.
When we host studies that are sponsored by other
organisations or companies, we also undertake
our own system of review (audit), in order to
ensure best practice and optimal safety for our
patients. In 2014, we aimed to audit 10% of all
active trials (19 trials), and we actually reviewed
21 studies to ensure that our staff are meeting all
of the regulatory and compliance requirements,
and patient safety is maintained.
Our aims in 2015
I. Increase participation
We intend to maintain and improve upon our
patient participation rates in NIHR adopted trials
at 2013 levels, understanding that 2014 was an
unusual year. We hope to recruit 5,000 patients or
more in 2015.
We intend to ensure that patients are made aware
of the research opportunities at the trust. In order
to do this we will participate in the International
Clinical Trials Day on 20th May.
We will also be running research focused articles
in the St George’s gazette, which is available to
patients and the local community.
II. Approvals
In 2015, we intend that at least 80% of our trials
are approved by the Joint Research and Enterprise
Office (JREO) within 15 days.
We have already noticed an increase in the
number of proposed studies, and we intend to
meet the challenge of approving more studies in a
shorter time.
III. Trials starting recruitment
We intend to continue increasing the number of
trials that get up and running quickly so that the
trials can be successful. We hope to achieve 80%
or relevant trials recruiting their first patient within
70 days.
IV. Ensuring quality
We will continue to review 10 per cent of all active
research studies each year to provide assurance of
the safety and quality of studies undertaken here.
We will continue to provide our clinicians with the
opportunity to take time to develop their ideas to
write successful grant applications. We will allow
clinicians time to recruit patients to trials in their
daily roles and support them with research staff.
https://www.gov.uk/good-clinical-practice-for-clinical-trials
1
14
15
ANNUAL REPORT 2014/2015
Participation in clinical audits
During 2014/15, 37 national clinical audits and five national confidential
enquiries covered NHS services that St George’s University Hospitals NHS
Foundation Trust provides.
During that period St George’s participated in
97.3 per cent of national clinical audits and 100
per cent of national confidential enquiries of the
national clinical audits which we were eligible to
participate in.
The national clinical audits and national
confidential enquiries that St George’s was
eligible to participate in during 2014/15 are
listed in Appendix A alongside the number of
cases submitted to each audit or enquiry as a
percentage of the number of registered cases
required by the terms of that audit or enquiry.
The reports from the 28 national clinical audits
were reviewed by trust board in 2014/15. A
summary of the actions agreed in response to
these audits is given in Appendix B.
The reports of 19 local clinical audits were
reviewed by St George’s in 2014/15. A summary
of the actions agreed is given in Appendix C.
Use of CQUIN payment framework
A proportion of our income in 2014/15 was conditional on meeting quality
improvement and innovation goals. These are objectives agreed between the
trust and its commissioners and clinical commissioning groups, through the
Commissioning for Quality and Innovation (CQUIN).
They key aim of CQUINs is to support a shift towards
a vision where quality is the organising principle.
The framework therefore helps ensure that quality is
always part of discussions between commissioners
and healthcare providers everywhere.
We achieved 90 per cent overall performance against
the 33 CQUINs we agreed with our commissioners for
quarters one to three in 2014/15 and envisage to do
so for Q4. Last year we achieved 87 per cent of our
CQUINs.
Following commissioner review and approval the
forecasted financial achievement will be in excess
of £10.5m.
Further details of the agreed goals for 2014/15
can be found in a dashboard in appendix D.
Percentage CQUINs Achieved
100
90
80
70
60
50
40
30
20
10
2011/12
2012/13
2013/14
2014/15
QUALITY ACCOUNT
16
Statement from the Care
Quality Commission
The Care Quality Commission (CQC) is the independent regulator of health
and social care in England. It regulates care provided by the NHS, local
authorities, private companies and voluntary organisations that provide
regulated activities under the Health and Social Care Act 2008.
The CQC registers, and therefore licenses, all
NHS trusts. It monitors trusts to make sure they
continue to meet very high standards of quality
and safety. If services drop below the CQC’s
essential standards it can require action to be
taken, impose fines, issue public warnings, or
launch investigations. In extreme cases it has the
power to close services down.
St George’s University Hospitals NHS Foundation
Trust is registered with the CQC and is licensed
to provide services from each of its locations. The
trust has no conditions placed on it and the CQC
has not taken any enforcement action against the
trust in 2014/15.
In May 2013, Professor Mike Richards was
appointed as Chief Inspector of Hospitals and
under his leadership, a new style CQC inspection
and a new framework of standards has been
developed which focus upon five domains:
•Are services safe? Are people protected from
abuse and avoidable harm?
•Are services effective? Does people’s care and
treatment achieve good outcomes and promote
a good quality of life, and is it evidence based
where possible?
•Are services caring? Do staff involve and treat
people with compassion, kindness, dignity and
respect?
•Are services responsive? Are services organised
so that they meet people’s needs?
•Are services well led? Does the leadership,
management and governance of the organisation
assure the delivery of high-quality patient-centred
care, support learning and innovation and
promote an open and fair culture?
The CQC rating system has four categories –
outstanding, good, requires improvement or
inadequate. NHS trusts are given an overall rating
and a range of services within the trust are also
given one of these four ratings.
How did we do?
In February 2014 the trust was subject to a
full inspection using the new CQC inspection
methodology against the five domains. The CQC
inspected the treatment and care provided at
St George’s Hospital, Queen Mary’s Hospital, St
John’s Therapy Centre and selected community
services provided from other health centres in
Wandsworth.
The CQC found the overall standard of care to be
good across all sites and has awarded the trust an
overall good rating, with some aspects of care rated
as outstanding. St George’s and Queen Mary’s
Hospitals both received good overall ratings.
The CQC rated 62 specific standards. Out of
these, four were rated outstanding, 50 were
rated good and eight were in the ‘requires
improvement’ category. None of our services
were judged inadequate. The full breakdown of
how our hospitals performed against each of the
five CQC essential domains is available over the
coming pages.
17
ANNUAL REPORT 2014/2015
CQC statement on St George’s Hospital
SERVICE
CQC ESSENTIAL CQC ESSENTIAL CQC ESSENTIAL CQC ESSENTIAL CQC ESSENTIAL OVERALL
DOMAIN
DOMAIN
DOMAIN
DOMAIN
DOMAIN
– SAFE
– EFFECTIVE
– CARING
– RESPONSIVE – WELL LED
A&E
Good
Not assessed
Good
Good
Good
Good
Medical care
Requires
Improvement
Good
Good
Good
Good
Good
Surgery
Requires
Improvement
Good
Good
Good
Good
Good
ITU/CCU
Outstanding
Good
Good
Good
Outstanding
Outstanding
Maternity
Good
Good
Outstanding
Good
Good
Good
Children &
Young People
Good
Good
Good
Good
Good
Good
End of
Life Care
Requires
Improvement
Good
Good
Good
Requires
Improvement
Requires
Improvement
Outpatients
Requires
Improvement
Not assessed
Good
Good
Good
Good
Overall
Requires
Improvement
Good
Good
Good
Good
Good
CQC statement on Queen Mary’s Hospital
SERVICE
CQC ESSENTIAL CQC ESSENTIAL CQC ESSENTIAL CQC ESSENTIAL CQC ESSENTIAL OVERALL
DOMAIN
DOMAIN
DOMAIN
DOMAIN
DOMAIN
– SAFE
– EFFECTIVE
– CARING
– RESPONSIVE – WELL LED
A&E (Minor
Injuries Unit)
Requires
Improvement
Not able to rate
Good
Good
Good
Good
Surgery
Good
Good
Good
Good
Good
Good
Outpatients
Good
Not able to rate
Good
Requires
Improvement
Good
Good
Community
Inpatient
Services
Good
Not rated at
this time
Not rated at
this time
Not rated at
this time
Not rated at
this time
Not rated at
this time
Overall
Requires
Improvement
Good
Good
Good
Good
Good
The audit of our community services at Queen
Mary’s Hospital, St John’s Therapy Centre and other
health centres was a pilot to help the CQC develop
the methodology for auditing community services
in the future. The CQC is not yet rating community
services so no rating was given for the community
inpatient service at Queen Mary’s or for the services based at St John’s and our other health centres.
The CQC reported its findings back to us at a
quality summit that included representatives from:
• St George’s University Hospitals NHS Foundation Trust
• The CQC
• The Trust Development Authority (TDA)
• NHS England
• Wandsworth Council
• Healthwatch Wandsworth
• Wandsworth CCG
• Merton CCG
In its report on the trust, the CQC highlighted
numerous examples of commendable practice,
including:
• outstanding maternity care underpinned by
information provided to women and partners and
robust midwifery staffing levels with excellent
access to specialist midwives
• exceptional end of life care demonstrated within
the maternity department
• outstanding leadership of intensive care and high
dependency units with open and effective team
working and a priority given to dissemination of
information, research and training
• excellent multidisciplinary working within and
across community and acute teams
• the functioning of the hyper acute stroke unit,
short term reablement and rehabilitation service
• the well led, integrated working and calm
environment within A&E
18
QUALITY ACCOUNT
• multi-professional team working in neuro theatres
• systems developed by the trust to promote the
safety of children, young people and families
• an evident culture of positive learning from
medicine administration errors
• development and use of DVDs to engage staff
with ongoing practice improvements.
As well as highlighting some aspects of care
which required improvement the CQC also asked
that we take action to ensure staff awareness
and implementation of the Mental Capacity Act
at Queen Mary’s Hospital. The CQC noted that
most staff had attended or completed training on
safeguarding adults and that there was appropriate
specialist input through the trust’s safeguarding
lead and two specialist learning disability nurses.
However, varying levels of understanding of the
Mental Capacity Act were identified.
Since the February inspection the trust has taken
action to address the two issues identified by the
CQC. A formal action plan was developed and
approved by the trust board before being shared
with the CQC. The plan set out how the trust would
ensure improvements in the availability of medical
records in outpatient clinics, it also set out the
measures we would take to ensure that trust staff
at Queen Mary’s Hospital (QMH) have a good level
of understanding of the Mental Capacity Act in
order to deliver safe, responsive and effective care.
There has been an improvement project in the
corporate outpatient department and better
availability of medical records was just one of
the improvements made. This improvement is
monitored on an ongoing basis.
The trust designed and delivered a tailored
training programme to all staff at QMH around the
implementation of the Mental Capacity Act and all
staff have now attended and have evaluated the
training and a case note audit showed practice
had improved.
Progress on the action plan has been presented
to the trust’s commissioners and the CQC on a
quarterly basis and both commissioners and the
CQC have indicated that they are assured good
progress has been made to improve quality of care
where needed.
Data quality
The collection of data is vital to the decision making process of any
organisation, particularly NHS trusts like St George’s. It forms the basis for
meaningful planning and helps to alert us to any unexpected trends that
could affect the quality of our services.
Most data is gathered as part of the everyday
activity of frontline and support staff who work
throughout the trust in a huge variety of settings.
It is important that we accurately capture and
record the care we provide and the information in
this report aims to demonstrate how well we are
doing this. We have been working closely with our IT
suppliers this year to increase the robustness of our
data capture and processing.
St George’s submitted records during 2014 for
inclusion in the Hospital Episode Statistics (HES)
which are included in the latest published data.
HES is the national statistical data warehouse of
the care provided by English NHS hospitals and
for NHS hospital patients treated elsewhere. The
body provides a data source for a wide range of
healthcare analyses of the NHS, government and
many other organisations and individuals.
The percentage of records in the published data
which included the patient’s valid NHS number was:
VALID NHS NO
2014/15 (M8)
2013/14
2012/13
2011/12
2010/11
National Average
2014/15 (M8)
APC
98.6
98.7
98.3
97.7
97.3
99.1
OP
99.4
99.4
99
98.6
98.6
99.3
A&E
92.7
93.4
95.1
94.5
94.4
95.1
2010/11
100
2011 12
80
60
2012/13
40
2013/14
20
2014/15 (M18)
0
APC
OP
A&E
National Average 2014/15
(M18)
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ANNUAL REPORT 2014/2015
Our NHS Number completeness remains good,
but is still fractionally behind the national average
for admitted care and A&E. We have a data
quality improvement strategy which we have
developed with our commissioners that details
planned improvements in the way our Patient
Administration System (PAS), Cerner, accesses the
national Patient Demographic Service (PDS) that
should see these numbers improve next year.
The percentage of records in the published data
which included the patient’s valid general medical
practice was:
RECORDS
WITH VALID GP
NUMBER
ADMITTED OUTPATIENT
CARE
CARE (PER
(PER
CENT)
CENT)
A&E
(PER
CENT)
2014/15 (M8)
100
100
100
2013/14
100
100
99.9
2012/13
100
100
100
2011/12
100
100
100
2010/11
100
100
100
National Average
2014/15 (M8)
99.9
99.9
99.2
2010/11
100
80
2011 12
60
2012/13
40
2013/14
20
2014/15 (M18)
0
APC
OP
A&E
National Average 2014/15
(M18)
Note: The data quality figures shown above are correct
as at month 8 (April 2014 to November 2014 data).
This is the most recent data available.
We continue to achieve exemplary scores in
registered GP practice recording, where we perform
better than the national average across admitted,
outpatient and A&E services.
Information governance
Information governance is the term used to describe the standards and
processes for ensuring that organisations comply with the laws, regulations
and best practices in handling and dealing with information. Information
governance ensures necessary safeguards for, and appropriate use of,
patient, staff and business information.
The key objective of information governance is to
maintain high standards of information handling by
ensuring that information used by the organisation is:
•Held securely and confidentially
•Obtained fairly and efficiently
•Recorded accurately and reliably
•Used effectively and ethically
•Shared appropriately and lawfully.
We have an ongoing information governance
programme, dealing with all aspects of
confidentiality, integrity and the security of
information.
Annual information governance training is
mandatory for all staff, which ensures that
everyone is aware of their responsibility for
managing information in the correct way. An
internal audit conducted in 2014/15 gave the
trust ‘reasonable’ assurance that the trust is
managing information appropriately and that staff
are aware of their responsibilities.
Our patient administration system increased both
the security and accuracy of information at the
trust. All staff accessing the system use a secure
and strictly authenticated smartcard which defines
what they are permitted to access in the system.
Virtual desktops are now in use across two thirds
of the trust, increasing the security and availability
of our systems.
The trust has introduced a new electronic system
for managing referrals improving both the accuracy
and allocation of appointments. The trust has
begun the implementation of an electronic
document scanning project, moving away from a
dependence on paper records.
20
QUALITY ACCOUNT
How did we do?
Each year we submit scores and provide evidence
to the Department of Health (DH) by using the
NHS Information Governance Toolkit. The toolkit is
an online system which allows NHS organisations
and partners to assess themselves against DH
information governance policies and standards.
It also allows members of the public to view each
organisation’s score and compare them.
The trust’s information governance assessment
report overall score for 2014/2015 was 77 per
cent and was graded green, or ‘satisfactory’
according to the criteria set nationally. This is
the highest grading possible, and can only be
awarded by achieving an attainment Level 2
on every requirement in the NHS Information
Governance Toolkit.
The information quality and records management
attainment levels assessed within the Information
Governance Toolkit provide an overall measure
of the quality of data systems, standards and
processes within an organisation.
You can explore the information governance scores
for St George’s, and other organisations, at https://
www.igt.hscic.gov.uk. St George’s is listed as an
acute trust and our organisation code is RJ7.
YEAR
INFORMATION
GOVERNANCE
ASSESSMENT
SCORE (PER CENT)
GRADE
2014/15
77
Green
2013/14
79
Green
2012/13
79
Green
2011/12
77
Green
Clinical coding error rate
Why is this important?
Clinical coding is the translation of medical
terminology written down by a healthcare
professional. It describes the patient’s complaint,
problem, diagnosis, treatment or reason for
seeking medical attention, using a coded format
which is nationally and internationally recognised.
The system uses healthcare resource group (HRG)
codes, which identify procedures or diagnoses
that have been judged to consume a similar level
of resource. For example, there are a number of
different knee-related procedures that all require
similar levels of resource, so they may all be
assigned to one HRG code.
Therefore, for every consultant episode (a period
of care under one consultant) and hospital spell (a
period of care from admission to discharge), each
patient is assigned an HRG code.
HRG codes consist of five characters: two letters
followed by two numbers and a final letter. The
first two letters correspond to body areas or body
systems, identifying the area of clinical care that
the HRG falls within. The final letter identifies the
level of complexity associated with the HRG.
Healthcare providers are paid based on the
HRG coding system. This is known as Payment
by Results (PbR). The aim of PbR is to provide
a transparent, rules-based system for paying
hospitals for the work they do. It is very important
that we code patient care accurately, so that we
are paid appropriately for the complexity of the
care we provide.
How did we do?
St George’s University Hospitals NHS Foundation
Trust was not subject to the Payment by Results
clinical coding audit during 2014/15 by the Audit
Commission.
We were last subjected to the PbR clinical coding
audit in 2012/13, when we were in the best
performing 25 per cent of trusts in the country.
AUDIT COMMISSION
(ALL SERVICES)
ERROR
RATE (%)
ERROR
RATE (%)
INCLUDING
ALL ERRORS
6.5
6.5
Secondary diagnoses incorrect
8.6
9.9
Primary procedures incorrect
1.3
1.3
Secondary procedures incorrect
8.3
14.1
ADMITTED
PATIENT
SPELLS
% OF
EPISODES
CHANGING
HRG
AA
100
14
LA
100
0
Total
200
7
Secondary procedures incorrect
8.3
14.1
Primary diagnoses incorrect
SUBCHAPTER
ANNUAL REPORT 2014/2015
HRG ERROR RATE
PERFORMANCE MEASURE (%)
HRG & Clinical Coding Error Rate
St George's 2014/15
7
10
St George's 2013/14
#N/A
8
St George's 2012/13
4
St George's 2011/12
7.4
St George's 2010/11
9
CLINICAL CODING
ERROR RATE
Performance Measure (%)
21
PERFORMANCE INC ERRORS
MEASURE (%)
St George's 2014/15
7.2
St George's 2013/14
#N/A
St George's 2012/13
7.8
St George's 2011/12
3.9
St George's 2010/11
9
8.7
6
4
2
0
2010/11
2011/12
HRG Error Rate
2012/13
2013/14
2014/15
Clinical Coding Error Rate
Note: The results should not be extrapolated further
than the actual sample audited. HRG subchapters
AA (Nervous System Procedures and Disorders) and
LA (Renal Procedures and Disorders) were reviewed
within the sample.
Improving patient safety
Reducing medication errors
Over the years we have worked hard to develop
and maintain our strong reporting culture.
Following their audit of the trust in February 2014,
the CQC reported that there is an evident culture
of positive learning from medicine administration
errors at St George’s.
This year the National Reporting and Learning
System have reported that St George’s medication
error reporting is higher than the national
benchmark for reporting medication incidents. Last
year we reported 1,574, reflecting a good safety
culture at the trust. Of these incidents, 92 per
cent resulted in no harm, 5 per cent in low harm
and 3 per cent in moderate harm. There were no
medication errors that resulted in severe harm
to patients. The most common types of error are
omissions and delays to administer medication
and administering the wrong dose of medication.
No harm – 93 per cent
Low harm – 5 per cent
Moderate harm – 2 per cent
Severe harm – 0 per cent
Medication incident reporting is up over a third over the
previous year, but the degree of harm is unchanged.
We have an intensive medication safety teaching
programme for clinical staff and our pharmacy
team manage a comprehensive audit programme,
including auditing prescribing accuracy, medicines
reconciliation, antibiotic point prevalence,
medicine handling and medication safety. The
pharmacy medication safety team also co-ordinate
medication safety monitoring visits to clinical areas
to monitor medication safety issues.
During 2014/15 medication safety visits have
been extended to community services and nonward areas including radiology and endoscopy.
QUALITY ACCOUNT
22
Reducing patient falls in the
community and whilst under the
care of the hospital
Why is this important?
People aged over 75 suffering falls is one of
the main causes of emergency admissions to
hospitals. Incidents of falls within healthcare
environments equally contribute to the length of
stay of complex patients, as well as presenting a
risk to both patients and the organisation.
Unfortunately, we will never be able to completely
eliminate the risk of our patients falling. We know
that even in the community one in three people
over the age of 65 will fall, rising to one in two
for over 80 year olds. However we also know that
falling is not an inevitable part of ageing and that
reversible risk factors can be addressed to reduce
the risk of falling and fracturing.
The inpatient hospital population has some of the
similar characteristics as the community dwelling
population, and in addition there are the additional
risks around acute illness and sudden change in
environment which presents further challenges for
those impaired by cognition/vision etc. Following
the acute phase of management the patient begins
their rehabilitation. An inherent part of patient
rehabilitation is risk taking, which must balance
the management of risk with the need to facilitate
progress and enable goal attainment. We try to
make sure that a multifactorial falls and bone
health risk assessment is completed and that a
care plan to reduce the individual’s risk factors is
implemented, providing a quality patient experience
within a safe environment.
How did we do?
Hospital inpatient services:
We have developed an electronic multifactorial
falls risk assessment in line with the NICE falls
guidelines and in line with the Wandsworth
community based falls and bone health risk
profile –to enable an exchange of meaningful
assessment information for comparison of
patient status and facilitate a smooth exchange
of discharge information. We have developed and
implemented a bed rails risk assessment tool
which must be completed for all adult inpatients
on admission to hospital. We have developed
patient information leaflets on falls prevention
and the use of bed rails. We have been running
monthly patient simulation study days to promote
best clinical practice for falls and other harms.
In some clinical areas we have trialled bed and
chair sensors which can be used as an adjunct to
falls prevention in some patients. We are looking
at exploring other technology which may help in
falls prevention.
There has been no significant reduction in the
number of inpatient falls across the trust this year.
Community based services:
The integrated falls and bone health service
(IFS&BH) is predominantly a prevention focused
service that dovetails with other reactive
community services. A major part of this team’s
work has been around ensuring that a falls and
bone health risk profile is completed irrespective
of the service that the patient accesses so that
the prevention of falls and fractures is seen as
a core role for all staff. The risk profile has been
modified to fit with the existing services. It is
a standard part of the service provision for the
following teams:
•IFS&BH
•CAHS (community adult health services)
•Community neuro team
•Brysson Whyte Rehabilitation Unit
•Day Hospital at St John’s Therapy Centre
•Community nursing, community matrons and
specialist nursing.
The IFS&BH service provides community based
multifactorial assessments with actions plans
agreed with the patient to address the reversible
risk factors identified. Part of the service provision
is the running of 25 community based exercise
groups a week – six of these with transport
to ensure a fair and accessible service to all.
The joined up approach across community
services and with the acute service along with
the expansion of the IFS&BH team and service
provision has ensured that there is greater
capacity to provide specialist intervention for the
populations at risk of fall and fractures.
ANNUAL REPORT 2014/2015
morph into a truly integrated service – improving
the seamless care that these patients receive.
There are further plans this year to build on this
work for the most frail populations of patients with
osteoporosis to ensure that services are delivered
in a timely fashion in the right place for this group.
2012 saw the launch of the Bone Boost
programme to provide a care pathway for people
with osteoporosis or osteopenia to reduce the
incidence of fragility fracture in Wandsworth. In
2014 the service was awarded the SLMC (South
London Membership Council) Recognition Award
for outstanding contribution to the community.
Watch a video about the Bone Boost service and
the impact it has had on the patients who have
been referred to it at www.stgeorges.nhs.uk/
services/senior-health/bone-boost
Our aims
We aim to reduce the current rate of reported
falls during an inpatient episode and continue
to reduce the admissions for falls patients in
Wandsworth in 2015/16. We will continue to
identify the trends and themes and implement
targeted action plans through structured
evaluation and benchmark ourselves against other
organisations when possible.
Building on the success of joint working with
the acute based osteoporosis service further
development work has continued to enable an
acute based service and a community service to
NHS Wandsworth Non-elective Emergency Admissions
(Patients 65 and over with a fall coded (W00 - W19) in ICD 1 to 5. Source data SUS
400
350
300
250
200
150
100
50
Original Admissions forecast
2014/15 Q4
2014/15 Q3
2014/15 Q2
2014/15 Q1
2013/14 Q4
2013/14 Q3
2013/14 Q2
2013/14 Q1
2012/13 Q4
2012/13 Q3
2012/13 Q2
2012/13 Q1
2011/12 Q4
2011/12 Q3
2011/12 Q2
2011/12 Q1
2010/11 Q4
2010/11 Q3
2010/11 Q2
2010/11 Q1
2009/10 Q4
2009/10 Q3
2009/10 Q2
0
2009/10 Q1
23
All Falls Admissions
Patient safety thermometer
Making sure that patients do not suffer avoidable harm is a key focus for
the trust and one of the priority areas in our “Sign up to Safety” plans.
This year we have consolidated our use of the national safety thermometer
across community and inpatient services.
The safety thermometer is a quick and simple
point-of-care tool for surveying patient harms and
analysing results so that you can measure and
monitor local improvement and harm free care.
Developed by the NHS for the NHS, the safety
thermometer collects data on high risk areas
including falls, pressure ulcers, urinary catheter
related infections and blood clots. The safety
thermometer allows us to merge patient safety
data across all the teams and wards in the
trust, with the built-in analysis charting functions
allowing us see the results straight away so we
always have a clear picture of what is happening
in any service at any time.
QUALITY ACCOUNT
We now have regular and reliable data for all of the
high risk areas listed above across all inpatient
and community services. All data recorded on the
safety thermometer is submitted to the Health
& Social Care Information Centre with monthly
national reports developed and published at
www.hscic.gov.uk/thermometer Teams can then
be given feedback on the percentage of their
patients who are “harm free” which gives them a
powerful tool for improvement.
24
The monthly data shows that 94.4% of our
patients were free of the harms being measured in
this way. This compares with a national benchmark
of 93.8 per cent.
A new patient safety thermometer for medication
safety has been piloted on some of our wards
and we are considering use of further pilots in
paediatric and maternity services.
Implementing the early warning
score indicator at HMP Wandsworth
Why is this important?
How did we do?
We provide all healthcare and substance
misuse services to the 1,665 offenders at HMP
Wandsworth, the largest prison in the UK. The
Jones Unit is a six bedded inpatient facility in the
prison. The unit is a step down from a hospital
ward and is used for offenders whose condition
needs closer monitoring than can be provided on
an outpatient basis whilst they stay in their cell.
Prisoners requiring isolation are also located on the
Jones unit. The unit reduces the need for unwell
offenders to be transferred to St George’s Hospital,
freeing up beds in the hospital for other patients.
The early waning score indicator has been
successfully implemented at HMP Wandsworth
with all patient observation charts on The Jones
Unit including the indicator. All offender healthcare
service staff have been trained on use of the
early warning scare indicator meaning that any
deterioration is identified quickly.
The early warning score indicator is a simple
tool in a patient’s observation notes used by
medical and nursing staff to determine the
severity of illness. A number of observations
are regularly recorded on the chart which allows
any deterioration to be quickly identified. The
observations recorded are:
•Heart rate
•Respiratory rate
•Blood pressure
•Level of consciousness
•Oxygen saturations
•Temperature.
The early warning score indicator has been used
at St George’s and Queen Mary’s Hospital for a
number of years and our aim for 2013/14 was
to introduce the early warning score indicator to
offender healthcare services.
Our aims
The national Early Warning Score (nEWS) has been
implemented on the Jones Unit. Further work
is required in 2015/16 to maintain consistent
approach in the use and recording of nEWS.
Currently, nEWS is recorded in paper format. In
2015/16 exploratory work will be undertaken to
devise an electronic template so that the nEWS
is integral to clinical information system and to
patients’ medical record.
25
ANNUAL REPORT 2014/2015
Mortality
Why is this important?
The summary hospital level mortality indicator
(SHMI) is intended to be a single consistent
measure of mortality rates. It shows whether the
number of deaths linked to an organisation is more
or less than would be expected, when considered
in light of average national mortality figures, given
the characteristics of the patients treated there. It
also shows whether that difference is statistically
significant.
Our outcomes
Our SHMI continues to be amongst the lowest in
country, with our mortality categorised as lower than
expected for two consecutive years. The table below
summarises the quarterly publications for this period.
PUBLICATION REPORTING PERIOD
DATE
RATIO BANDING
April 2014
October 2012 –
September 2013
0.78 Lower than
expected
July 2014
January 2013 to
December 2013
0.80 Lower than
expected
October
2014
April 2013 to
March 2014
0.81 Lower than
expected
January
2015
July 2013 –
June 2014
0.84 Lower than
expected
Source: Health and Social Care Information Centre
At St George’s we continue to use the hospital
Standardised Mortality Ratio (HSMR) in addition
to the SHMI to monitor mortality. The chart below
shows our performance over the last few years.
With the HSMR, if our mortality matched the
expected rate our score would be 100. The HSMR
indicates that St George’s mortality is consistently
significantly better than expected.
Hospital standardised mortality ratio
As it includes all deaths the SHMI makes
no adjustment for palliative care. The Health
and Social Care Information Centre publishes
contextual indicators to support interpretation
of the SHMI, one of which is ‘the percentage of
deaths with palliative care coding’. This presents
crude percentage rates of deaths that are coded
with palliative care either in diagnosis or treatment
fields. The data displayed below shows the
percentage of deaths with palliative care coding
for the trust compared to the national average.
PUBLICATION REPORTING
DATE
PERIOD
ST
GEORGE’S
NATIONAL
April 2014
October 2012
– September
2013
21.0%
20.9%
July 2014
January 2013
to December
2013
23.6%
22.0%
October
2014
April 2013
to March 2014
26.2%
23.6%
January
2015
July 2013
– June 2014
27.6%
24.6%
Our aims
100
80
HSMR
Palliative care coding
Source: Health and Social Care Information Centre
120
60
These data are reviewed by the trust’s mortality
monitoring committee which meets on a monthly
basis. The group, which is chaired by the
associate medical director for governance and has
members from across the Trust also considers
mortality data at diagnosis and procedure level
and reviews all deaths in hospital following an
elective admission. By examining this range of
data we are able to scrutinise our outcomes and
the care we provide to patients. Where there are
lessons to be learnt these are identified and acted
upon and where best practice is observed this is
acknowledged and shared.
80
83
86
87
84
40
SGH
20
National ave.
0
10/11
11/12
12/13
Financial year
Source: Dr Foster Intelligence
13/14
YTD:
Apr14 - Nov14
As previously our aim for the coming year is to
maintain our strong performance and consistently
achieve a mortality ratio which is lower than
expected. We will achieve this by continuing and
expanding our scrutiny of deaths and taking action
as necessary.
QUALITY ACCOUNT
26
Assessing risk of VTE in
admitted patients
Why is this important?
Venous thromboembolism (VTE) is a condition
where a blood clot forms in a vein, which can
cause substantial long term health problems.
Risk assessments for VTE ensure that we intervene
with preventative measures at the earliest possible
time according to the needs of each patient. It also
helps us to identify any instances of deep vein
thrombosis or pulmonary embolus occurring within
90 days of admission so that we can investigate
and learn how to avoid these in the future.
The focus on this condition has helped to improve
practice and ensure that our patients are treated
safely.
How did we do?
All trusts across the country need to report the
number of documented VTE risk assessments
being conducted on admission as a proportion of
the total number of hospital admissions.
We also have to report the proportion of those
cases where there is a documented risk
assessment that appropriate thromboprophylaxis
has been prescribed.
110,817 patients were admitted at St George’s
and Queen Mary’s Hospitals between April and
February 2014/15. 106,218 of these were
documented on their discharge summary as being
given VTE risk assessments, which is 95.8 per
cent. The national target for VTE risk assessments
is 95 per cent. In 2013/14 we documented risk
assessments for 95 per cent of 116,256 patients.
Percentage Patients Risk Assessed for VTE
97
95
93
91
89
87
85
2011/12
2012/13
2013/14
2014/15
National Target
2014/15
Root cause analysis of VTE cases at
St George’s and Queen Mary’s Hospitals
Following on from the CQUIN last year root cause
analysis continues to be carried out in cases
identified as hospital acquired thrombosis. We
have identified 98 cases which have had their
index admission at St George’s. In those who had
previously been admitted to another hospital, we
have notified those hospitals of the case. All 98
cases at St George’s, have been notified to the
admitting consultant and to the care group and
divisional leads.
Root cause analysis has been completed in 78
(79.6 per cent) of these cases. This exceeds the
national target of 75 per cent. Results show that
risk assessment was carried out in 95.8 per cent
of patients and appropriate prophylaxis given in
65.9 per cent of cases. Reasons for inadequate
prophylaxis included failing to record the reasons
for prophylaxis doses not being given, not
escalating the dose for patients who weighed more
than 100kg, and failure to reassess patients who
were at high risk of bleeding on admission. These
findings have been presented at the specialties’
governance and care group meetings and actions
to improve practice have been implemented
In 2015/16 year the VTE prevention programme
will continue to be included as a key performance
indicator for the trust.
Our aims
VTE prevention and treatment is a top clinical
priority for St George’s. We are amongst the
highest performing trusts in the country for VTE
prevention, but we are working hard to make
further improvements.
27
ANNUAL REPORT 2014/2015
To help us further improve the number of patients
risk assessed and the number of patients given
appropriate thromboprophylaxis we will continue
our programme of training, education and feedback
across the trust. Basic VTE training has been
added to the trust’s mandatory training programme
that all staff have to complete every year.
To ensure that all new staff are aware of the
importance of VTE risk assessments, we have
made VTE awareness part of the staff induction
programme that all staff have to complete
before starting work with us, and have developed
specialist VTE training programmes for junior
doctors. Our clinical divisions now have named
VTE leads, and we have recruited junior doctor and
physician associate VTE champions, new roles to
further raise awareness of the important of VTE
prevention amongst medical staff.
We have also invested extra resources into extra
consultant time to be dedicated to VTE risk
assessments and teaching, and have a specialist
VTE nurse supporting assessments, teaching,
auditing and awareness across the trust.
Our performance against both of these indicators
will be continue to reported on a monthly basis
at divisional governance meetings, with divisional
VTE leads helping to maintain awareness of the
importance of VTE assessments across all of
our wards.
To further increase the profile of VTE prevention
we have implemented the national Safety
Thermometer which looks each month at high
risk areas including VTE, falls, pressure ulcers,
urinary catheter related infections and blood clots,
and have introduced a harm free care study day
for nursing and midwifery staff which has VTE
prevention as one of the modules.
Infection control
Why is this important?
The prevention and control of healthcare acquired
infections at St George’s is a top priority. Our
aim is to make our facilities as clean and safe
for patients as possible. Alongside the cleanliness
of our wards, we also continue to focus on our
programme of comprehensive training for staff,
stringent hand hygiene and careful use of antibiotics.
We use an array of measures to stop the spread
of infection to patients. Our infection control team,
made up of doctors and nurses, works around the
clock, monitoring infections and providing ward
staff with advice on how to prevent, treat and
contain the spread of infection to patients.
What is C.difficile?
Clostridium difficile (C.difficile) is a bacteria
that can cause mild to severe diarrhoea and
inflammation of the bowel. C.difficile infection can
be prevented by a range of measures, including
good hand hygiene, careful use of antibiotics and
thorough environmental cleaning. By monitoring the
prevalence of infections acquired in hospital, we
can introduce better measures to reduce the risk of
infection for all of our patients.
C.difficile is present naturally in the gut of around
three per cent of adults and 66 per cent of
children. However, some antibiotics that are used
to treat other health conditions can interfere with
the balance of ‘good’ bacteria in the gut. When this
happens, C.difficile bacteria can multiply and
cause symptoms such as diarrhoea and fever.
As C.difficile infections are often caused by
antibiotics, most cases usually happen in a
healthcare environment, such as a hospital or
care home. Both appropriate and inappropriate
antibiotic use can cause C.difficile infection and
there is always a balance of risk in treating patients
with antibiotics. A strong antimicrobial stewardship
program is important to ensure appropriate antibiotic
usage only. Transmission can occur from patient to
patient however with good modern infection control
practices this is not common, although in the past
it was far more common. Older people are most at
risk from infection, with the majority of cases (80
per cent) occurring in people over 65.
Most people with a C.difficile infection make a full
recovery. However, in rare case the infection can be
protracted and occasionally fatal.
Our C.difficile outcomes
37 patients acquired C.difficile whilst under our
care during 2014/15. This is an increase on the
previous year although we achieved our nationally
agreed threshold of 40. It was agreed with the
local commissioning support unit that of the
30 cases reviewed 23 cases were unavoidable
28
QUALITY ACCOUNT
(77 per cent) and seven cases there was some
element of lapse of care (23 per cent).
YEAR
NUMBER OF PATIENTS –
ACQUIRED C.DIFFICILE
Number of patients - acquired C.difficile
100
80
60
2014/15
37
40
2013/14
30
20
2012/13
62
0
2011/12
86
2010/11
52
Threshold 2015/16
31
2010/11
2011/12
2012/13
2013/14
2014/15
Threshold
2015/16
Our aim
Our 2015/16 target is to prevent all avoidable
C.difficile infections and acquire no more than our
nationally agreed threshold 31 cases of C.difficile
Rate of patient safety incidents and
percentage resulting in severe harm
or death
Why is this important?
Modern healthcare is increasingly complex and
occasionally things go wrong, even with the best
practices and procedures in place.
An open reporting and learning culture is important
to enable the NHS to identify trends in incidents
and implement preventative action. The rate of
reported patient safety incidents (unintended or
unexpected incidents which could have led, or did
lead, to harm for one or more patients receiving
NHS healthcare) is expected to increase as a
reflection of a positive patient safety culture.
This view is supported by the National Patient
Safety Agency who state “organisations that
report more incidents usually have a better and
more effective safety culture. You can’t learn and
improve if you don’t know what the problems are”.
Patient safety incidents
There were 10,187 reported patient safety
incidents in 2014/15 compared to 9,739 the
previous year. This shows that we continue
to actively report as many incidents as we
can, demonstrating that at St George’s we are
committed to developing good systems that
enable us to learn from things that go wrong and
prevent them from happening again.
Of the 10,187 patient safety incidents there were
31 high and extreme severity incidents during the
year. This is 0.3 per cent of all reported patient
safety incidents.
YEAR
2014/15
2013/14
2012/13
2011/12
NUMBER OF PATIENT
SAFETY INCIDENTS
10,187
9,739
9,084
9,663
The number of never events declared over this
period was five. None of these incidents resulted
in harm to the patient.
DIVISION
Surgery
Women’s
Women’s
Women’s
Community services
SERVICE
Dentistry
NEVER EVENT
Retained Foreign
Object (Throat Swab)
Obstetrics
Retained Swab
Obstetrics
Retained Swab
Obstetrics
Retained Swab
Dermatology Wrong site surgery
Over the last year we have introduced some
important changes to help us reduce any risk to
our patients. We have:
•Carried out a patient safety week which has
focussed on staff concerns
•Carried out regular staff open forums so that staff
are aware of safety messages
•Taken part in the national Sign up to Safety
Campaign and identified our priorities for
improvement.
29
ANNUAL REPORT 2014/2015
Improving patient experience
Community learning disability referrals
Why is this important?
The Wandsworth Community Learning Disability
Health Team (CLDHT) is a multi-professional team
providing community based healthcare for adults
with learning disabilities. The service facilitates
access to generic NHS services.
The service is provided in the setting most
appropriate to the service users’ needs. This can
be in their own home, place of work or education,
in the community, in an NHS facility, or at the
CLDHT team base.
Our CLDHT provides a person-centred, multidisciplinary community service to people who need
a specialist learning disability service, so there
may be just one or several CLDHT professionals
involved with a service user at any one time. Most
service users have a network around them which
can include family members and a range of health
and social care providers. Working collaboratively
with colleagues in the CLDHT and the service
user’s network is essential for the delivery of a
quality service that meets their needs.
It is important that people referred to the
service are assessed for eligibility within a four
week period. This is so we can make sure that
people with learning disabilities are in receipt of
appropriate care to support their complex health
needs as soon as possible.
Confirming eligibility for CLDHT services is a time
intensive process that can be delayed by, for
instance, accessing healthcare records. Once a
referral is received the service user will follow the
eligibility pathway, and as soon as it is established
the individual has a learning disability they will be
accepted by the CLDHT.
If the referral is for somebody who is already
known to the CLDHT they will be accepted straight
away. If the person is unknown to the CLDHT there
is a three stage process to determine eligibility.
The referral can be accepted at any point where
there is sufficient evidence of a learning disability:
•review of documentation such as past
assessments, IQ tests, reports, Statements of
Educational Needs
•initial screening test
•IQ test (e.g. Wechsler adult intelligence scale)
and social functioning assessment (e.g. Vineland
or adaptive behaviour assessment system)
To receive the CLDHT service, clients must have a
learning disability which is:
•impaired intelligence (a significantly reduced
ability to understand new or complex information
and learn new skills with an IQ of less than 70)
•impaired social functioning (a reduced ability to
cope independently)
•both of which started before adulthood with a
lasting effect on development.
If at any point in the eligibility process, it becomes
clear the person does not have a learning
disability, they will be signposted to the most
appropriate service. If the individual is assessed
as having a learning disability but it is felt they are
not in need of specialist services for their specific
problem, they will be signposted to the most
appropriate mainstream service.
How did we do?
2013/14 was the first year we formally reported
on the rate of patients going through the eligibility
pathway within 28 days of referral. Because of
this we had a target that increased every quarter,
with our target starting at making sure 80 per cent
of service users referred between April and June
2013 were assessed within 28 days, increasing
to 95 per cent for those referred between January
and March 2014.
For the first quarter of 2014/15 we achieved our
target by making sure that 80 per cent of referred
service users were assessed. 100 per cent of
patients referred between July 2013 and March
2014 were assessed within 28 days.
For 2014/15, 100% of patients referred to the
service were seen on the eligibility pathway within
28 days of receipt of the referral.
30
QUALITY ACCOUNT
Complaints
Why is this important?
Number of complaints
Last year we had more than one million
appointments and inpatient stays at our hospitals
and in the community. With this number of
patients and appointments, we know that there
will unfortunately be times when we do not meet
the expectations of our patients.
We encourage our patients and their friends, family
and carers to let us know when this happens so
we can make the changes that are needed to
improve.
As well as dealing directly with our staff, patients
and their friends, family and carers can also
discuss any concerns they have with our Patient
Advice and Liaison Service who will work with them
and the service to resolve any issues. Complaints
and compliments can also be formally submitted
to our complaints and improvements department.
We aim to investigate and provide a full response
to all formal complaints within 25 working days of
the complaint being received.
The lessons learned and trends identified from
information collected from our complaints process
play a key role in improving the quality of our
services and the way we engage with our patients
and visitors.
Our outcomes
In 2014/2015 we received 1052 formal
complaints, a slight reduction compared to 1,083
complaints in 2013/14.
It is very difficult to benchmark complaints against
other trusts as there is no uniform way for trusts
to record complaints, meaning there is a lot of
inconsistency across the NHS.
We view all types of patient feedback as positive
and we are constantly looking at how we can
encourage patients, carers and families to give
their views.
1400
1200
1000
800
600
400
200
0
2014/2015
2013/2014
2012/2013
2011/2012
2010/2011
Complaints response rate
We fully responded to 68 per cent of complaints
within 25 working days. Our target is that 85 per
cent of complaints are fully responded to within
25 working days.
We fully responded to 84 per cent of complaints
within 25 working days or an agreed timescale.
Our target is that 100 per cent of complaints are
fully responded to within 25 working days or an
agreed timescale.
The chart below tracks performance throughout
the year. Whilst performance regarding responding
to complaints within agreed timescales improved
throughout the year to almost 100 per cent in
March, hitting the 25 working day target is proving
to be a challenge in some areas. A focussed piece
of work is underway to ascertain the reasons
for each late response so that actions can be
taken regarding any themes or areas of particular
concern that are identified.
Complaint response times by month
100%
90%
80%
70%
60%
50%
Number of complaints
40%
NUMBER OF COMPLAINTS
30%
% within 25 working days
% within 25 agreed timescales
Mar-15
Jan-15
Feb-15
Dec-14
Oct-14
Nov-14
1253
Sep-14
2010/2011
0%
Jul-14
1031
Aug-14
2011/2012
10%
Jun-14
825
Apr-14
2012/2013
20%
May-14
1083
Mar-14
2013/2014
Jan-14
1052
Feb-14
2014/2015
Dec-13
YEAR
31
ANNUAL REPORT 2014/2015
Patient advice and Liaison Service (PALS)
Improving patient experience
Our Patient Advice and Liaison Service (PALS)
received 7662 contacts in 2014/15, of which 3,567
were concerns rather than information requests. In
2013/14 PALS received 6,943 contacts, of which
2,674 were concerns.
1. we will listen to and involve people who use
our services
2. we will use feedback as a vehicle for continuous
improvement adopting best practice where possible
3. we will ensure that our patients are cared for in
a clean, safe and comfortable environment
4. we will ensure that our most vulnerable patients
and service users are listened to and protected
from harm
5. we will protect patients’ dignity
6. we will focus on the fundamentals of care that
matters to patients.
Our PALS is a patient friendly, easy to access
advice, help and information service for patients
and their family, friends and carers. The PALS team
listen to any concerns people have and help to find
ways of resolving them. The team also take note of
every contact and feedback to our clinical services
so that we can make improvements for our patients.
You can find out more about PALS on our website at
www.stgeorges.nhs.uk/patients-and-visitors
Our aims
We are clear that we must improve our response
rate to complaints, making sure that we significantly
increase the number of complaints responded to
within 25 days.
As well as making sure we acknowledge and
respond fully to all complaints in a timely fashion, we
will also work to make sure we continue to adhere
to use complaints to make improvements. Some
improvements made in response to complaints
received in 2014/2015 are in the table below.
CONCERN
Trauma and
orthopaedics
(delays in clinic)
Cardiothoracics
(pain management)
Transport (delays)
Offender healthcare
(various
How to make a complaint
If you would like to make a complaint or compliment
about any aspect of our service you can email
complaints.compliments@stgeorges.nhs.uk or
write to use at:
Complaints and Improvements Department
St George’s Hospital
Blackshaw Road
London, SW17 0QT
ACTION
Restructuring of fracture clinic to reduce delays. We now have a consultant who is not booked to
see patients, but sits in a central control room so that they can offer advice and support to the
registrars who see a high volume of patients. They can advise in complex clinical cases and as they
do not have their own list of patients, are easily accessible to all registrars. This has reduced delays
in fracture clinic and improved patient care.
An increase in complaints related to pain management particularly where bank/agency staff have
been looking after patients was noted. The sister and matron have developed a quick reference
guide and a leaflet for staff explaining the unique pain patients experience post thoracic surgery.
The thoracic clinical nurse specialist is also producing short booklets on common thoracic surgery
and post-operative complications to help temporary staff in managing these patients. A second CNS
for thoracics is being appointed which will help allow the majority of patients to be pre assessed.
This will allow greater discussion about post-operative care so the patient will be aware what to
expect and understand how to use the patient controlled analgesia alongside oral analgesia.
A training schedule was set up in December 2014 and all trust staff now have access to training
on the transport systems and processes on a monthly basis. The training covers issues such as
ensuring the correct transport booking is submitted and escalation procedures are reinforced to
ensure delays to patient journeys are minimised.
In response to complaints a number of actions have been taken, some general and some more
specific including:
•every quarter, a group of randomly selected prisoners are sent invitations to meet with the head
of offender healthcare to provide feedback on healthcare services.
•a healthcare professional regularly attends to prisoner wing forum to obtain feedback.
•each November prisoners are invited to complete a prisoner survey and the results are
compared to the previous year.
•standardised guidance is being produced for a clinician to promote best practice and provide
training for all clinicians in ear care.
•a patient information leaflet will be made available to patients presenting with ear wax
impactation. This is being produced by the clinical lead nurse for the offender healthcare
service and will be completed by the end of October.
32
QUALITY ACCOUNT
Contacting PALS
You can visit the PALS office between 9am and
5pm, no appointment is needed. You can find PALS
on the ground floor of Grosvenor Wing at
St George’s Hospital.
Alternatively, you can contact PALS by phone on
020 8725 2453. If you call outside of normal office
hours a member of the PALS team will return your
call the next working day. You can also email PALS
at pals@stgeorges.nhs.uk
Responding to patients’ needs
Why is this important?
% Recommend
Patient experience is a key measure of the quality
of care. At St George’s, we continually strive to
be more responsive to the needs of our service
users, including needs for privacy, information and
involvement in decisions. In 2014, St George’s
received the results of the national cancer patient
experience survey.
% Recommend
80
75
70
65
60
Aug-14 Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Inpatient
A&E
Trust
Maternity
Mar-15
The scoring is based on the percentage of people
that said they were “Extremely likely” or “Likely”
to recommend our service if a friend or family
member needed similar care or treatment.
The FFT has now been in place for two years,
having been rolled out in A&E and inpatient adult
areas for April 2013, maternity in October 2013
followed by outpatient and community services in
September 2014.
The maternity survey is different from A&E and
adult wards as there are four occasions or ‘touch
points’ when women are asked to rate the service
(antenatal, birth, postnatal ward and postnatal
community) whereas A&E and inpatient adult
areas is only once on discharge.
Response Rates
Friends and family test
50
45
40
35
30
25
20
15
10
5
15
15
Inpatient CQUIN Target
A&E CQUIN Target
b-
b-
Inpatient Actual
A&E Actual
Fe
Fe
4
15
c-1
nJa
De
4
v-1
4
No
4
-1
t-1
Oc
14
g-
Se
p
4
-1
ar
M
Au
4
r-1
Ap
14
0
-1
4
Percentage
The friends and family test is a national
initiative and asks patients on discharge about
how likely they are to recommend our hospital
wards, accident and emergency department and
maternity services to a friend or relative based on
their treatment. There are six options; Extremely
likely, Likely, Neither likely nor unlikely, Unlikely,
Extremely unlikely or Don’t know.
85
n-
In 2013 a new measure was introduced – the
friends and family test (FFT).
90
Ju
l
Building on work already undertaken, St George’s
is committed to the delivery of the highest
standards of care for patients. The national
cancer patient experience survey indicated that
we need to focus on the areas outlined above and
therefore the trust has made this area a priority
for improvement during 2015/16.
95
Ju
The results indicated that St George’s was one
of the ten most improved trusts within the NHS
which was encouraging and a testament to
the team who had delivered the improvement.
However, the survey also indicated that the trust
still had work to do in a number of areas. One of
these was in relation to patients’ perception about
the quality of communication between staff and
patients, particularly when patients were admitted
to the trust. In addition, the survey indicated that
there is an opportunity to improve the knowledge
for staff working with patients who have cancer in
order to improve the quality of service provision.
100
33
ANNUAL REPORT 2014/2015
When you had important questions to ask did you get
Do you think the hospital staff did everything they could do
Did you feel that you were involved in decisions about our
Overall did you feel you were treated with respect and
Were you ever bothered by noise at night from other
Did a member of staff tell you about medication side
Were you given enough privacy when discussing your
Did you find someone on the hospital staff to talk to about
Were you involved as much as you wanted to be in
50.0%
For 2014/15, there was a minimum target for the
number of surveys completed. A&E was required
to achieve a response rate of 15 per cent (rising
to 20 per cent) and inpatient wards were required
to achieve a response rate of 25 per cent (rising
to 30 and then 40 per cent by March 2015).
In addition we also have a number of other survey
questions that we ask patients (anonymously)
about their experience based on the national
annual inpatient survey. A bespoke system
allows for almost real-time feedback to enable
staff to share good practice and implement any
actions that may be required. We will continue to
undertake national surveys but hope this process
allows for more rapid feedback and action. The
data above is a summary for the year outlining the
additional questions with the percentage relating
to positive answers.
Staff use word clouds to display comments from
patients in their clinical areas. Our word clouds
A word cloud from a patient survey.
60.0%
70.0%
80.0%
90.0%
100.0%
give greater prominence to the words that appear
most often in our survey results.
National inpatient survey
The national inpatient survey is conducted every
year by the CQC to find out how patients aged 16
or over who spent at least one night in hospital
felt about their experience. As in 2013, the 2014
survey was split into 10 sections with trusts given
a score between 0 and 10 for each section. As
well as the scored for each section, trusts were
ranked as being “better” than most other trusts
in the country (green), “about the same” as most
other trusts in the country (amber) or “worse”
than most other trusts in the country.
We were ranked as being “about the same” as
most other trusts in the country in all 10 sections.
This was also the case with the 2013 survey.
QUALITY ACCOUNT
SURVEY SECTION
SCORE
A&E department
8.6
Waiting list and planned admissions
8.6
Waiting to get to a bed on a ward
7.2
The hospital and ward
7.9
Doctors
8.5
Nurses
8.2
Care and treatment
7.7
Operations and procedures
8.4
Leaving hospital
7.2
Overall views of care and services
5.4
Overall experience
8.0
34
A workshop was held on 20 March 2015 where
the detailed report provided by our survey
contractor was analysed. Areas for improvement
were identified and these were:
•cleanliness of toilets
•need for additional equipment or home
adaptations to be discussed with patients
•confidence and trust in nurses
•assistance at mealtimes
•noise at night from patients and staff
•communication about bathrooms and toilets
(separate male and female).
A further workshop will be held to develop an
action plan.
End of life care
Why is this important?
What we will do?
In February 2014 end of life care was reviewed
as part of our CQC inspection. The services
offered by the specialist palliative care team, the
bereavement team and mortuary teams were
considered to be excellent.
In 2014/15 we received £15,000 of CQUIN money
to train facilitators on Sage and Thyme Foundation
Level Communication skills. The Sage and Thyme
Model can be taught to any member of staff (e.g.
healthcare assistants, doctors, administration
staff) in contact with distressed people (not just
patients) in any setting (e.g. hospital, nursing
home, social care). As part of the end of life care
approach for 2015/16 we will be focussing on the
development, and roll out of this training across
the trust for staff working in both acute and
community settings.
Patients had treatment plans explained, and
relatives were included in the care planning
process. There were good interactions between
staff and patients and families had experienced
good end of life care.
However the CQC indicated that there was a lack
of strategic direction for end of life care from
the top of the organisation. As a result, the trust
implemented during 2014/15 a programme of
work to address the CQC concerns.
Under the leadership of the chief nurse a
programme board has been established from
operational and palliative care leads to deliver an
agreed programme of work to ensure that there
is a stronger strategic framework in place and the
trust is meeting the priorities from the Department
of Health “One Chance to get it right” document.
Our aims
Our aim will be to deliver the training programme
to an agreed number of staff during the year. The
actual number will be agreed by the end of Q1
2014/15. The end of life programme board will
monitor progress against this target.
35
ANNUAL REPORT 2014/2015
Improving patient outcomes
Sexual health in secondary schools
Why is this important?
Supporting young people to grow up with a good
knowledge about their sexual health and how to
both protect themselves and keep safe is really
important. Historically, Wandsworth has had a high
teenage pregnancy rate which has halved in the last
10 years due to improved services and education.
Schools are responsible for providing sex and
relationships education. St George’s provides
school nursing services in Wandsworth.
To improve access to sexual health advice,
support and signposting our school nursing
service provides a drop in service in secondary
schools in Wandsworth. Our target is for 50 per
cent of secondary schools in Wandsworth to have
sexual health support on the school grounds.
How did we do?
All 11 secondary schools in Wandsworth have a
school nurse who spends up to three days a week
in the school supporting pupils.
These schools also have a weekly drop-in session
when pupils can see a school nurse confidentially
(there is always the need however to inform pupils
that if a safeguarding concern is raised this will
need to be shared).
All of our school nurses have received training in
sexual health and the administration of emergency
contraception, with a patient group direction (PGD)
and competency framework for the administration
of emergency contraception developed and
implemented.
Sexual health information is freely available in
all secondary schools. Information is also given
to pupils about The Point sexual health clinics in
Wandsworth, with pupils actively encouraged to
attend if they are likely to be sexually active.
Our aims
We have three main aims for young people in
Wandsworth:
•to have quick and easy access to sexual health
information in a confidential and appropriate way
giving them the option to make informed choices
about their sexual health
•to be protected from harm
•to have easy access to emergency contraception
where a holistic assessment will be carried out
by a school nurse. This then gives the opportunity
to make sure the young person is safe and
address any other health concerns.
Update March 2015
This continues to be a school nursing service
priority. The school nurses offer sexual health
advice during drop-in sessions. Only two secondary
schools have agreed to the administration of
emergency contraception in school at present.
Clinical outcome measures in
community services
Interventions can extend over a long period and
care can focus on many different issues, not
just illness but promoting health and wellbeing.
These factors can make it hard to measure
clinical outcomes in community services. The NHS
continues to work with professional bodies like the
Royal College of Nursing and Chartered Society of
Physiotherapy to develop the best way to measure
clinical outcomes.
During 2014/15, while some progress was made,
we do not yet have measurable outcome data.
During 2015/16 we’ll focus on the development
of our data collection processes and define key
outcome measures.
36
QUALITY ACCOUNT
Patient reported outcomes
measures (PROMS)
Why is this important?
Patient reported outcome measures (PROMs) assess
the quality of care from the patient’s perspective.
Covering four procedures they calculate health gains
after surgical treatment using short, self-completed,
pre – and post-operative questionnaires.
Our outcomes
The table below shows the percentage of patients
who reported an increase in their health following
surgery, using three scoring methods, which are
explained briefly below. The range is between 0 and
100 and higher scores are better. This makes no
adjustment for the type of patients treated.
Hip replacement
(primary)
Hip replacement
(revision)
For all four procedures EQ-5DTM and EQ-VAS
indices measure a general view of health, and
for three there is also a measure specific to the
condition treated.
•EQ-5DTM is a combination of five key criteria
concerning general health
•EQ VAS assessed the current state of the
patient’s general health marked on a visual
analogue scale
•Condition specific measures include a series of
questions specific to the patient’s condition.
APR11 – MAR12
(FINAL)
APR12 – MAR13
(FINAL)
APR13 – MAR14
(PROVISIONAL)
APR14 – SEP14
(PROVISIONAL)
SGH
Eng.
SGH
Eng.
SGH
Eng.
SGH
Eng.
87.8
87.3
100
89.7
*
89.3
*
90.6
EQ-VAS
57.9
63.6
72.2
65.5
*
65.1
*
66.7
Specific
93.2
95.7
95.0
97.1
83.3
97.2
*
97.5
EQ-5D
TM
-
-
68.4
72.3
62.5
70.0
*
70.1
EQ-VAS
-
-
47.1
53.7
62.5
52.1
*
49.3
Specific
-
-
78.9
84.6
66.7
83.2
*
88.0
EQ-5D
TM
Knee Replacement EQ-5D
(primary)
EQ-VAS
63.0
78.4
68.8
80.6
*
81.4
82.2
30.0
53.8
53.3
54.9
*
55.1
No data 56.5
Specific
76.5
91.6
86.7
93.2
*
93.8
94.2
TM
Knee Replacement EQ-5D
(revision)
EQ-VAS
-
-
*
67.5
*
81.4
*
-
-
*
49.0
*
55.1
No data *
Specific
-
-
*
82.1
*
93.8
*
EQ-5D
48.0
49.9
36.4
50.2
45.5
50.6
*
50.2
40.2
38.9
32.7
37.7
18.9
37.3
26.7
38.2
EQ-5DTM
58.2
53.2
48.6
52.7
50.9
51.8
0
53.4
EQ-VAS
50.0
42.0
26.7
40.9
30.8
40.1
50.0
40.9
Specific
81.5
83.1
79.4
83.3
74.5
83.6
85.7
84.9
TM
Groin hernia
TM
EQ-VAS
Specific
Varicose vein
Source: Health and Social Care Information Centre
Data notes: Total questionnaire count for survey and
procedure type is less than 30.
37
ANNUAL REPORT 2014/2015
The latest available data is for April 2014 to
September 2014 and does not allow us to
make comparison to the national picture as the
number of completed pre and post-operative
questionnaires is too low.
Adjusted health gain
Adjusted average health gains have been
calculated using statistical models which account
for the fact that each provider organisation treats
patients with a different casemix. This allows for
fair comparisons between providers and England
as a whole.
Data reported in the table below shows that for
the majority of measures there are insufficient
records for this analysis to be reported for St
George’s patients. This is true for all measures for
the partial year 2014/15.
Provisional data for 2013/14 shows that for
varicose vein surgery we are an outlier for two
of the three measures, meaning that our patient
reported outcomes are worse than the national
average. For groin hernia there is only one
measure available, and this shows our patient
reported outcomes to be worse than the national
average. The number of records is too low for
analysis of hip and knee replacement outcomes.
It should be noted that at St George’s we perform
only a small number of complex cases of knee
and hip replacements, with the majority of routine
cases being referred to the South West London
Elective Orthopaedic Centre for treatment.
APR11 – MAR12
(FINAL)
APR12 – MAR13
(FINAL)
APR13 – MAR14
(PROVISIONAL)
2014/15 YTD
(PROVISIONAL)
EQ-5D
*
*
*
*
EQ-VAS
*
*
*
*
Specific
Not outlier
*
*
*
EQ-5D
-
*
*
*
EQ-VAS
-
*
*
*
Specific
-
*
*
*
EQ-5D
*
*
*
No procedures
Knee Replacement EQ-VAS
(primary)
Specific
*
*
*
No procedures
*
*
*
No procedures
EQ-5D
Knee Replacement
EQ-VAS
(revision)
Specific
-
*
*
No procedures
-
*
*
No procedures
-
*
*
No procedures
Hip replacement
(primary)
Hip replacement
(revision)
EQ-5D
Groin hernia
Varicose vein
Not outlier
Not outlier
*
*
EQ-VAS
Not outlier
Negative 95%
outlier
Negative
95% outlier
*
Specific
Not applicable
EQ-5D
Not outlier
Not outlier
Not outlier
*
EQ-VAS
Not outlier
Negative 95%
outlier
Negative
95% outlier
*
Specific
Not outlier
Negative 99.8%
outlier
Negative
95% outlier
*
Source: Health and Social Care Information Centre
Data notes: *insufficient records
– split between primary and revision procedures was not made in 2011/12
QUALITY ACCOUNT
38
Participation
St George’s is responsible for providing patients
with the opportunity to complete pre-operative
questionnaires. Post-operative questionnaires
are sent by contractors working for the
Department of Health directly to patients that
have completed the initial survey. Our aim is to
provide the choice of completing the questionnaire
to all appropriate patients, however it is voluntary
and not all patients will choose to take part.
Our participation rate for the most recent period
considered here (April 2014 to September 2014)
is 41.1 per cent, which is below the national
average of 76.7 per cent.
Our participation rate for the most recent period
considered here (April 2014 to September 2014) is
41.1 per cent, which is below the national average
of 76.7 per cent. Local monitoring is in place and
following observation of a decline in submissions
at the start of the year a number of actions were
taken which resulted in a significant increase. We
therefore expect that our end of year position will
be much improved, which will in turn contribute to
increasing the availability of trust level data about
our patient reported outcomes. This work will
continue to be overseen by the Patient Experience
Committee.
APR11 – MAR12
(FINAL)
APR12 – MAR13
(FINAL)
APR13-MAR14
(PROVISIONAL)
APR14 – SEP14
(PROVISIONAL)
SGH
England
SGH
England
SGH
England
SGH
England
All procedures
64.5%
74.6%
66.8%
75.5%
77.4%
77.3%
41.1%
76.7%
Hip replacement
88.2%
82.3%
87.0%
83.2%
137.1%
87.1%
70.0%
86.1%
Knee replacement
101.7%
89.3%
127.9%
90.4%
137.5%
95.1%
140.0%
96.6%
Groin hernia
52.4%
60.6%
72.1%
61.7%
69.8%
60.8%
40.9%
58.3%
Varicose vein
68.9%
48.9%
34.3%
44.3%
71.7%
40.7%
31.1%
42.4%
Source: Health and Social Care Information Centre
Note: Participation rates of over 100% are possible for a number of reasons: an operation is cancelled following
completion of the pre-operative questionnaire; surgery is carried out by a different provider; coding issues.
Clinical records – driving quality
improvement through technology
Why is this important?
By March 2016, NHS England says that the Care
Quality Commission (CQC) will measure digital
maturity within healthcare settings as part of
their inspection regime. In addition, by 2020,
being ‘paperless’ will be a prerequisite for holding
an operating licence to provide publicly funded
healthcare.
These significant measures will mean that
successfully deploying electronic clinical
documentation is an even bigger priority for health
care professionals and health care providers. By
implementing an electronic clinical documentation
system the trust will enable transformational
programmes that focus on modernisation,
increased patient safety and greater productivity.
National initiatives: –
•Five Year Forward View – systems that ‘talk to
each other’ to enable different parts of the health
service to work together and harness the shared
benefits that come from interoperable systems
•patients being able to access their online records
and write in them
•‘NHS Paperless’.
Local drivers:•risk management, patient and staff safety
•real time reporting
•transparency and accountability
•aligned with CQUINs and KPIs.
39
ANNUAL REPORT 2014/2015
How did we do it?
Clinical documentation
We have deployed electronic clinical
documentation and electronic prescribing and
medicines management (ePMA) to 44 per cent of
the hospital. This has been supported by clinician
engagement in designing and implementing the
system. A comprehensive training programme was
devised to support the rollout.
The clinical functionality has created a driver
to ensure real time bed state is a reality in
wards that are live with clinical documentation.
Discharge summaries should now reach GPs
within 24 hours of discharge. Discharge summary
reports are cascaded on a daily basis to relevant
clinical leads.
Electronic Prescribing and Medicines
Administration (ePMA)
Venous thromboembolism (VTE) risk assessment
compliance in areas that are live is now
transparent as it is possible to report directly from
the electronic record. This has meant it has been
possible to target areas where compliance has not
been at the agreed level. Other risk assessments
such as pressure ulcer prevention assessment
and falls are now audited with greater ease.
The deployment of ePMA has delivered
patient safety benefits to the organisation.
This has resulted in improved adherence with
organisational policies including the following:
PREPOSTIMPLEMENTATION IMPLEMENTATION
Eliminating
incomplete
prescriptions
38.2%
Complete
100%
Complete
Eliminating
98.5%
inappropriate use of Appropriate use
dose units e.g. mcg
100%
Appropriate use
96.6%
Appropriate use
99.97%
Appropriate use
Reduction in
inappropriate drug
form and route
combinations
All patients with medications prescribed now
have allergies documented and signed, with an
improvement in the documentation of the nature
of the allergy.
100%
90%
80%
Percentage
70%
60%
50%
ePMA Results
(2015)
40%
30%
Paper Chart
Results (2014)
20%
10%
0%
Allergy
Documented?
Allergy
Nature?
Allergy
Documentation
Signed
Allergy Specific Documentation
National standards for antibiotic prescribing are
now being adhered to with 100% compliance.
100%
90%
80%
Percentage
70%
60%
50%
ePMA Results
(2015)
40%
30%
Paper Chart
Results (2014)
20%
10%
0%
Indication
Given?
Route of
Antibiotics Given?
Dose of
Antibiotics Given?
Antibiotic Specific Documentation
SPECIALITY
BED STATE % ON
10/03/15
Average
Cardiac
100%
Average
Neuro
100%
Average
Paeds
98%
Average
Renal
100%
Our aim
In 2015/16 we aim to further deploy electronic
clinical documentation and ePMA to inpatient
bed areas.
The clinical systems programme board will
continue to drive the deployment by monitoring:
•the deployment plan
•pre and post deployment support including the
use of ‘champion users’ and training
•risk associated with the transition from paper to
electronic processes
•issue logs to identify any themes or trends that
might impact patient care and safety
•future developments ie care pathways
•implementation of interactive white boards and
vital signs monitoring equipment
•data captured and data quality
•training for pre-registration students and
temporary staffing.
QUALITY ACCOUNT
40
Reducing hospital readmissions
Why is this important?
Monitoring emergency readmission rates can help
us to prevent or reduce unplanned readmissions
to hospital. An emergency readmission is recorded
when a patient has an unplanned readmission to
hospital within 30 days of a previous discharge.
This Quality Account refers to emergency
readmissions within 30 days rather than Health
and Social Care Information Centre compendium
indicator’s 28 days. This is because trusts report
on their emergency readmissions within 30 days
at frequent intervals as part of their quality
reporting and as per Monitor compliance and
NHS Trust Development Authority accountability
frameworks.
Reducing hospital readmissions is a substantial
and hugely challenging task given the financial and
regulatory constraints, but the potential benefits
are enormous to patients. We are committed to
reducing readmissions for all patients, whether
they have received emergency or elective (planned)
treatment, by making sure that all discharges
are properly planned and that patients are not
discharged until it is safe to do so, and that the
appropriate community and social services are in
place to support them in their own home when they
are ready to leave hospital. For patients admitted
for elective care, an important part of this process
is the pre-operative assessment, which reduces
the risk of complications during and following their
stay in hospital.
Reducing the number of emergency and elective
readmissions would ease the pressure on our
emergency department, which is one of the busiest
in the country. This would in turn create extra
capacity in the hospital for elective patients and
mean that less elective procedures are cancelled
because of surges in emergency activity. Reducing
elective readmissions would also mean that waiting
times for elective procedures could be reduced.
The risk is heightened in the winter when pressure
on our services increases significantly. We
have plans to help us to manage the surge in
attendance and admissions in the winter, including
opening a winter ward that is closed during warmer
months when there is less emergency activity.
We also have a complex modelling system that
helps us to predict how busy our emergency
department will be at any given time by analysing
activity levels over previous weeks and years.
This helps us to make sure that we have the
appropriate staffing levels in our emergency
department. This of course means that waiting
times are shorter, but more importantly that
our patients receive the care and attention their
condition needs.
How did we do?
Reducing emergency readmissions has always
been one of our priorities. In 2014/15, 3.2 per
cent of patients were readmitted to hospital within
30 days. In real terms this means that 4,500
patients were readmitted to hospital within 30
days of being discharged from their previous
emergency or elective admission. 3.38 per cent
of patients were readmitted within 30 days of
discharge in 2013/14.
7.0%
6.0%
5.0%
4.0%
2013/14
3.0%
2014/15
2.0%
1.0%
0.0%
Elective
readmissions rate
Non-elective
readmissions rate
Trust Total
readmissions
41
ANNUAL REPORT 2014/2015
Emergency Readmissions within 30 days
500
4.0%
400
3.0%
300
2.0%
200
1.0%
100
0.0%
0
May
Apr
Jun
Jul
13/14 No. of Readmissions
Aug
Sep
Oct
Oct
14/15 No. of Readmissions
EMERGENCY READMISSIONS 2013/14
WITHIN 30 DAYS
2014/15
Trust readmissions rate
3.38%
3.20%
Elective readmissions rate
1.40%
1.35%
Non-elective readmissions
rate
5.98%
5.69%
Our increased readmission rates highlight the
complexity of the challenges we face. As St
George’s Hospital is a major trauma centre, hyperacute stroke unit and heart attack centre, we treat
the most seriously ill patients and most complex
cases from across south west London and Surrey.
This means that the risk of patients needing to be
readmitted after leaving hospital is higher for St
George’s than or other acute trusts in that area.
We regularly receive patients via the helipad from
Sussex, Kent, Hampshire and further afield.
EMERGENCY
READMISSIONS
WITHIN 30 DAYS
PATIENTS PATIENTS OVERALL
AGED 0-15 AGED 16+ TRUST
Trust readmissions
rate
1.30%
3.50%
3.20%
Elective
readmissions rate
0.90%
1.40%
1.35%
Non-elective
readmissions rate
1.50%
6.80%
5.69%
Our community virtual wards provide a highly
responsive multi-disciplinary approach to the
management of patients with long term conditions
who are registered with a Wandsworth GP in
their own homes. By providing care to patients in
their own homes we can help to avoid emergency
attendances and readmissions for some patients
by addressing complications before they escalate
into serious issues.
Oct
Jan
13/14 Rate
Feb
Mar
14/15 Rate
Our four community virtual wards in Wandsworth
are helping us to treat patients with chronic long
term conditions who are more likely to need
acute services more effectively in the community,
reducing the number of patients who need to be
readmitted following discharge.
Our aims
Reducing hospital readmissions is a substantial
task given the financial, regulatory, and systemic
constraints. Reducing emergency readmission
remains one of our key priorities and a continued
area of focus for between St George’s and our
partners in primary care and local councils. Our
key focus is on readmissions for patients aged 16
and above as an readmission rates for paediatrics
are just five percent.
During 2015/16 we will continue our efforts
to reduce readmissions by making sure that all
discharges are properly planned, appropriate
community services are in place, and patients are
not discharged until it is safe to do so.
QUALITY ACCOUNT
42
Performance
INDICATOR
Mortality
TARGET
2014/15 PERFORMANCE
2015/16 TARGETS
Lower than
expected
mortality
rate
ACHIEVED – St George’s was identified by
the Health and Social Care Information Centre
(HSCIC) as one of 15 trusts that have had a
lower than expected mortality rate in the latest
period published (July 2013 to June 2014).
The trust has maintained this position for two
consecutive years.
Maintain lower than
expected mortality rate
Maximum time of 18 weeks
from point of referral to
treatment in aggregate –
admitted
>= 90%
Maximum time of 18 weeks
from point of referral to
treatment in aggregate – nonadmitted
>= 95%
Maximum time of 18 weeks
from point of referral to
treatment in aggregate –
patient on an incomplete
pathway
>= 92%
A&E: maximum waiting time
of four hours form arrival to
>= 95%
admission/transfer/discharge
Patients with suspected
stroke assessed face to face
who received an appropriate
care bundle from the trust
PARTIALLY ACHIEVED – 85.6%
The trust met the target for Q1. However the
Trust did not meet the target for Q2-4 2014/15,
as breach of RTT targets was authorised as
To achieve sustainable
part of the national RTT backlog reduction
compliance with 18
programme.
week waiting times
target for admitted and
non – admitted patients.
ACHIEVED – 96.3%
To improve specialty
level compliance in
PARTIALLY ACHIEVED – 91.4%
line with aggregate
The trust met the target for Q1. However the
achievement.
trust did not meet the target for Q2-4 2014/15,
as breach of RTT targets was authorised as
part of the national RTT backlog reduction
programme.
NOT ACHIEVED – 92.31%
The target was not met due to failure to meet
95% target in Q1, 3 and 4.
COMPLIANT – 62.7% – (percentage of patients
Compliance admitted to stroke unit who had actually had a
stroke)
Improve performance
above 95%
Maintain compliance
Improve performance
against 62 day wait
from urgent referral for
suspected cancer target,
with performance above
85%
62-day wait for first treatment
from urgent GP referral for
suspected cancer
>= 85%
PARTIALLY ACHIEVED – 85.6%
Performance is greater than target for year
cumulative Apr – Feb 2014/15. However the
target was not met in Q3.
62-day wait for first treatment
from NHS Cancer Screening
Service referral
>= 90%
ACHIEVED – 91.2%
Maintain and continue to
improve performance
31-day wait for second or
subsequent treatment –
Surgery
>= 94%
ACHIEVED – 98.6%
Maintain and continue to
improve performance
31-day wait for second or
subsequent treatment –
anti-cancer drug treatments
>= 98%
ACHIEVED – 100%
Maintain and continue to
improve performance
All cancers: 31-day wait from
diagnosis to first treatment
>= 96%
ACHIEVED – 97.7%
Maintain and continue to
improve performance
Cancer: two week wait from
referral to date first seen for
all urgent referrals (cancer
suspected)
>= 93%
ACHIEVED – 96.4%
Maintain and continue to
improve performance
43
ANNUAL REPORT 2014/2015
Clostridium C.difficile –
meeting the C.difficile
objective (M)
40
ACHIEVED – 38 cases against annual threshold No more than 31 cases
of 40.
of C.Diff during 2015/16
MRSA
0
NOT ACHIEVED – 6 cases of MRSA
Mixed Sex Accommodation
Breaches
0
Improve mixed sex
NOT ACHIEVED – The trust had 16 breaches of accommodation
mixed sex compliance in 2014/15
compliance to prevent
future breaches
Never Events
0
NOT ACHIEVED – The Trust had 5 Never Events No never events in
in 2014/15
2015/16
Certification against
compliance with requirements
regarding access to health
Compliance COMPLIANT
care for people with a learning
disability (Q)
To meet our target of
zero avoidable cases
Maintain compliance
Data completeness: community services, comprising:
referral to treatment
information
50%
ACHIEVED – 55%
Maintain and continue to
improve performance
referral information
50%
ACHIEVED – 88%
Maintain and continue to
improve performance
treatment activity information
50%
ACHIEVED – 70%
Maintain and continue to
improve performance
Note:
1. RTT performance reported is YTD average for April to February 2014/15.
2. Cancer performance reported is aggregate YTD for April to February 2014/15.
QUALITY ACCOUNT
44
Annex 1: Statements from
commissioners, Healthwatch and
Overview and Scrutiny Committees
Wandsworth CCG
(on behalf of local CCGs)
Wandsworth Clinical Commissioning Group (WCCG) works closely with
St George’s University Hospitals NHS Foundation Trust to ensure that it
provides high quality care for patients.
There are robust arrangements in place with the
trust to agree, monitor and review the quality
of its services. During 2014/2015 WCCG
requested a board to board with St George’s
University Hospitals NHS Foundation Trust which
gave commissioners the opportunity to share
concerns and agree an open approach with a clear
quality focus, there is an expectation that this
transparency continues.
The Clinical Quality Review Group meets monthly
and brings together GPs, senior clinicians and
managers from both St George’s University
Hospitals NHS Foundation Trust, Wandsworth
CCG, associate commissioners and NHSE. We
have received assurance throughout the year
from the trust in relation to key quality issues,
both where quality and safety has improved and
where it occasionally fell below expectations with
remedial plans put in place and learning shared
wherever possible.
WCCG recognises that St George’s University
Hospitals NHS Foundation Trust faces an
extremely challenging year in 2015/2016,
WCCG plans to actively engage with the trust
on strategies to mitigate the effects of financial
difficulties. It is our expectation is that quality will
be prioritised despite the challenging context,
we will therefore be implementing processes for
enhanced quality surveillance.
WCCG are disappointed that there will not be
CQUINS for the next financial year as we have
considered them to be a powerful vehicle for
improvement. We will continue to work with the
trust to identify alternative ways to continue to
progress these quality priorities.
The CQC report from the February 2014
(published in April 2014) found the overall
standard of care to be good across all sites within
the Trust. However there were eight areas which
needed improvement and the trust’s progress
with the subsequent the action plan has been
monitored by the Clinical Quality Review Group.
Wandsworth CCG commissioners have reviewed
the trust’s Quality Account for 2014/15 and
the summary of performance against national
standards, with expectations for the year ahead.
The Quality Account does cover many examples
of good quality within the trust and St George’s
University Hospitals NHS FT is open in identifying
some of its own weaknesses.
The CCG note that the ED (emergency department)
4-hour target has been challenging during 2014/15
and has not been consistently achieved over
the year. The CCG will continue to work with St
George’s University Hospitals NHS Foundation Trust
to address the challenge for the year ahead to
improve the flow of patients through the hospitals
to support the 4-hour target. Another challenging
area has been the achievement of the 18 week
referral to treatment target and cancer target of
maximum weight of 62 days from urgent GP referral
to first treatment (excluding rare cancers).
45
ANNUAL REPORT 2014/2015
WCCG would like to see an accelerated
improvement in respect of the issue of bullying
and harassment reported in the staff survey.
The trust has been open and honest in its
reporting of serious incidents to commissioners
during 2014/2015 and has taken positive steps
to learn for incidents and implement planned
actions. There have been five ‘never events’
reported throughout the year which has increased,
the CCG notes the work that the trust are
undertaking in obstetrics and surgery to address
the root causes of these incidents.
WCCG welcomes the continued focus on patient
safety and patient experience and has endorsed
the proposed quality indicators. We would like
to see the Clwyd Hart recommendations fully
implemented including asking complainants to
feedback on the complaints process.
WCCG regularly gathers feedback from GPs
and this has been used to identify primary care
clinician’s views and issues related to the care
provision at St George’s University NHS FT. The
trust has worked collaboratively in addressing the
issues highlighted by GPs and this demonstrates
the value that the trust places in this feedback.
The Quality Account could have reflected the good
work that has been undertaken as a result of this
feedback.
The CCGs fully endorse the proposals set out in
the Quality Account. WCCG can confirm to the
best of our knowledge that the account contains
accurate information in relation to the quality
of services provided by St George’s University
Hospitals NHS Foundation Trust. We welcome the
specific priorities for 2014/15 which the trust has
highlighted in the quality report; all are appropriate
areas to target for continued improvement and link
with clinical commissioning priorities.
QUALITY ACCOUNT
46
Wandsworth Council (OSC)
Statement from Wandsworth Adult Care and Health Overview and
Scrutiny Committee.
Whilst this statement is submitted on behalf of
the Wandsworth Adult Care and Health Overview
and Scrutiny Committee, the very tight timescale
allowed for its submission means that it has not
been possible to agree it at a Committee meeting.
The comments made reflect the established view
of the Committee and its work over the past year,
and have been prepared in consultation with its
leading members.
In previous years, statements from the Overview
and Scrutiny Committee on the Quality Account
have repeatedly highlighted the contrast between
the clinical excellence of many of the services
provided by St George’s and the much less
satisfactory measures of patient experience.
The current Quality Account again highlights
the significantly lower than average mortality
rates associated with treatment at St George’s.
However, on this occasion there are also
encouraging signs of improvements in patient
experience, with improved results in surveys of
the experience of users of cancer and maternity
services. There is still a long way to go, with
surveys of patient experience still rating the Trust
at no better than the national average, but the
direction of change is clearly positive.
The most evident challenge for the Trust over the
past year has been in managing the demand for its
services. Performance targets have been missed
in relation to the length of time patients spend in
the accident and emergency department, the 62day wait from GP referral to treatment for cancer,
the 18 week target for referral to treatment, and
the proportion of cancelled operations not rebooked within 28 days. We are aware that the
challenges the trust faces in the management
of demand are exacerbated by its role as a
provider of tertiary services, including its role
as a major trauma centre. Whilst the Overview
and Scrutiny Committee is strongly supportive of
these specialist functions, from which Wandsworth
residents benefit, it is important that they are
managed in a way that does not disadvantage local
patients who rely on the Trust for secondary care.
The Trust’s ability to manage high levels of demand
is also linked to the strength of its partnership
arrangements with Wandsworth CCG and other
local CCGs, and with the Council. Conversely, the
ability of Wandsworth Council and Wandsworth
CCG to achieve the targets set out in the Better
Care Fund plan is dependent upon actions to be
taken by the Trust. It is therefore important that
the Trust continues to prioritise local partnership
arrangements and to fully implement its
commitments made under those arrangements.
There remain some issues that have been a
long-standing concern for the Overview and
Scrutiny Committee which remain problematic. For
example, the proportion of complaints responded
to within the target timescale has consistently
been too low over several years. Whilst the
Trust’s acknowledgement that improvements are
needed is welcome, it is important that action on
this is prioritised and that a clear timetable for
improvement is set.
It is also a concern that, for the second year
running, that the Trust has reported five ‘never’
events. It appears that four of the five events
related to retained swabs. Whilst these may not
have resulted in harm to patients, it is important
that they are learnt from and action is taken so
that they do not recur.
The Overview and Scrutiny Committee is broadly
supportive of the priorities for 2015/16 set
out in the Quality Account, and welcomes the
introduction of an additional priority around end
of life care. However, a number of the targets
in relation to the local priorities – for example,
offender healthcare and sexual health in schools
– are entirely process-orientated. It would
be preferable to have an increased focus on
outcomes. The Overview and Scrutiny Committee
would also be supportive of a local priority on
‘parity of esteem’, seeking to ensure that people
with a mental disorder are not disadvantaged in
their use of acute care services.
Finally, the Overview and Scrutiny Committee
acknowledges that the Trust is currently facing
a very difficult financial position. It is important
that the Trust should find ways of dealing with this
that do not place at risk the safety or quality of
services offered to patients.
Richard Wiles, Chair 18/05/2015
47
ANNUAL REPORT 2014/2015
Healthwatch Wandsworth
For the purposes of HWW, the most important areas are patient safety,
patient experience and outcomes and performance indicators.
In the National NHS Staff Survey, staff are asked
whether “If a friend or relative needed treatment I
would be happy with the standard of care provided
by my organisation”.
In the 2014 survey, 73 per cent of St George’s
staff said that they agreed with the statement.
This is higher than the national average (median)
for acute trusts of 65 per cent, and higher than
last year when 68 per cent of staff said that they
agreed with this statement.
As well as giving an individual score for each
question, a score is calculated for a number of key
indicators based on the answers to the questions
grouped under each indicator. One of these key
indicators is staff recommendation of the trust as a
place to work or receive care. On a scale of 1-5, with
5 being the most positive, St George’s scored 3.78
compared to 3.67 nationally for acute trusts. Last
year its score was 3.73. This gives a very positive
view of the hospital’s standard, although over time,
we would like to see this increase even further.
As a commitment to improving quality, the trust
says: “We aim to further improve our score in the
staff recommendation of the trust as a place to
work or receive care indicator in the National NHS
staff survey and maintain our status as one of the
top 20 per cent of trusts in the country. We aim
to further improve our scores in the Friends and
Family staff survey in 2015.” We hope that this
can be achieved.
There is also quite a worrying figure, in that
31% of staff say that they have experienced
harassment, bullying or abuse from staff in the
past 12 months. The trust says it has a strategy
to tackle bullying including coaching and training
for managers dealing with difficult staffing issues,
tracking and following up the range of concerns
that were raised in the CQC inspection in 2014.
It is also worth noting that income generated by
the NHS services reviewed in 2014/15 represents
100 per cent of the total income generated from
the provision of NHS services by St George’s
University Hospitals NHS Foundation Trust for
2014/15, so at present, there are no competing
demands for private care at the Trust.
Patient safety
The Trust has a good record on patient safety
and in 2014, and in its inspection of the Trust
in February 2014, CQC reported that there is an
evident culture of positive learning from medicine
administration errors at St George’s, which is a
very positive finding in HWW’s view.
This year the National Reporting and Learning
System has reported that St George’s medication
error reporting is higher than the national
benchmark for reporting medication incidents,
which indicates openness by clinicians, another
positive sign. Last year it reported 1,574 errors,
reflecting a good safety culture at the trust. Of
these incidents, 92 per cent resulted in no harm,
5 per cent in low harm and 3 per cent in moderate
harm. There were no medication errors that
resulted in severe harm to patients.
We welcome the hospital’s commitment to
reducing the number of inpatient falls – SGH says
it aims to reduce the current rate of reported
falls during an inpatient episode and continue
to reduce the admissions for falls patients in
Wandsworth in 2015/16. It has also committed to
identifying the trends and themes and implement
targeted action plans through structured
evaluation, which is again very positive.
The trust also has a good venous
thromboembolism (VTE) assessment in place,
which HWW welcomes. The national target for VTE
risk assessments is 95 per cent, and in 2013/14,
the trust achieved risk assessments for 95 per
cent of 116,256 patients.
The Trust has a very robust infection control
programme in place and is not above the national
average on cases. Its target in 2015/16 target
is to prevent all avoidable C.difficile infections
and acquire no more than our nationally agreed
threshold 31 cases of C.difficile.
In terms of patient safety incidents, there were
10,248 (provisional data) reported patient safety
incidents in 2014/15 compared to 9,772 the
previous year. Only a very tiny percentage of these
led to patient harm, and as the Trust says, it
shows that there is a culture of openness in the
QUALITY ACCOUNT
organisation, and reporting incidents can help to
improve standards in the long term.
The hospital’s record on medical research is
impressive, in its role as a teaching hospital, and
the number of local people taking part in clinical
trials has increased substantially in recent years,
which is very encouraging and allows local people
to help to improve health services for all. This is a
great example of collaboration between the Trust
and its local population.
Patient experience
The number of complaints received by the Trust
has remained broadly the same for the last few
years – in 2014-2015 it received 1052 formal
complaints, a slight reduction compared with
1,083 complaints in 2013-14. Given that the
number of patient interactions/consultations at
the hospital is probably several million a year, this
is a very good record and shows the high standard
of services overall.
The National Patient Survey, carried out by CQC
in which the Trust participates, appears to give
a slightly mixed picture: inpatient and maternity
services perform well but satisfaction with A&E
services appears to be falling, based on figures
for 2013-14. This is an area which needs special
attention and we are aware that the Trust is
currently trying to address the issues of capacity
and demand.
The results of this year’s inpatient survey are not
yet available and have not been included in the
QA. We hope that they continue to show a good
general level of 3 satisfaction.
The Friends and Family Test, which was
introduced in 2013, is a useful indicator of patient
satisfaction, but it does not have any statutory
penalties attached to poor performance, and so
HWW believes this is a limited tool.
The programme of Quality Inspections conducted
by St George’s has been supported by HWW –
both from a policy perspective and by providing
volunteers to act as patient representatives
on inspections. HWW has advocated for
improvements in the programme, some of which
have been implemented. It is therefore of concern
to HWW that the QI programme has been stopped
due to unfilled staff vacancies. It is hoped that the
programme will be restarted as soon as possible
because of its benefits to St George’s staff and
the potential for keeping standards of care as high
as possible.
48
Patient outcomes
The Trust has a generally good standard of patient
outcomes, according to figures obtained as part
of their CQC inspection. However, two areas that
need some improvement are the outcomes of
varicose vein surgery and groin hernias, in which
the Trust falls below the national average. We
would like to see some progress in these areas in
time for next year’s QA.
The Trust appears to be doing some very good
work in reducing hospital readmissions. In
2014/15, only 3.2 per cent of patients were
readmitted to hospital within 30 days. In real
terms this means that 4,500 patients were
readmitted to hospital within 30 days of being
discharged from their previous emergency or
elective admission. This is very impressive
achievement and we hope that this level can be
maintained or improved on in the longer term.
Performance indicators
The Trust has performed well on most of its
performance indicators, including mortality rates
and cancer treatment waiting times. On mortality
rates, the Trust deserves recognition for being one
of only 15 Trusts in the country identified by CQC
as having lower than expected mortality rates.
Cancer waiting times are within the 18-week
limit specified in the NHS Constitution. However,
A&E waiting times continue to be the problem
area, and HWW realises there is no easy answer
to these difficulties. As one of the busiest A&E
departments in the country, the Trust faces major
challenges, particularly after a winter in which A&E
admissions nationally have increased. The Trust is
trying to address these problems and we hope to
have further meetings with Trust representatives
to discuss how these can be resolved.
Ambra Caruso, Healthwatch Wandsworth Manager
18/05/2015
49
ANNUAL REPORT 2014/2015
Healthwatch Merton
Healthwatch Merton would formally like to recognise the achievement of
St George’s acquiring Foundation Trust status over the last year, which
recognises the high quality services and safe care provided at St George’s
hospital and in the community.
Healthwatch Merton is pleased to see that St
George’s Hospital has performed well across most
of its performance indicators. Healthwatch Merton is
also happy that the trust has been tackling the issue
of hospital readmissions over the past year and have
seen a reduction in this. We ask that St George’s
continues to tackle and improve on reducing the
number of readmissions in the coming year.
We were pleased to read in the Care Quality
Commission report that ‘there is a positive culture
of learning from medicine administration errors’,
this only further supports the trust’s good record on
patient safety over the past year and its commitment
to continued improvement and self-learning.
On the subject of learning, Healthwatch Merton
recognises the trust’s good work as a teaching
hospital and the excellent medical research that it
does. We note that the research work has seen an
increase in the number of local people taking part
in helping to improve medical provision and services
for the better.
Notes of caution
A&E waiting times continue to be problematic and
though we are aware that the trust is continually
trying to find solutions, we ask that you ensure you
work with the many local Healthwatches surrounding
the trust to aid you in doing this.
In addition to this A&E satisfaction rates seem to be
dropping and highlight that this department needs a
particular focus. Healthwatch Merton has identified
A&E as a workstream for 2015/16 and would like to
work with the trust in the coming year on this.
A happy and motivated staff team works and
interacts better with its patients, families and
others when managed in a supportive, learning and
open environment. It is therefore concerning that
a third of staff have reported experiencing bullying,
harassment and abuse from other staff in the past
year. We acknowledge the trust has a strategy to
tackle this and hope to see the number of staff
experiencing this dramatically reduced in the coming
year, which can only be better for the people St
George’s Hospital serves.
Healthwatch Merton Manager.
18/05/2015
QUALITY ACCOUNT
Healthwatch Lambeth
Healthwatch Lambeth is pleased to provide this response to St George’s
Hospital Quality Accounts for 2014/15.
Healthwatch Wandsworth work more closely
with St George’s Trust than we do and provide
volunteers to act as patient representatives on
inspections. Healthwatch Lambeth endorses their
more detailed analysis of the evidence presented
under patient safety, patient experience and
outcomes and performance indicators in the
accounts.
The Quality Account shows many good standards
of patient safety, experience and outcomes
including evidence obtained during the recent CQC
inspection. However, we are concerned to read
that 31% of staff say that they have experienced
harrassment, bullying or abuse from staff in the
past 12 months and hope that future accounts
are able to show real progress as a result of the
strategy to tackle bullying. All people caring for
people, especially people who are ill, need to be
treated with dignity and respect so they can deliver
outstanding experience and outcomes.
Our work in Lambeth during 2014/15 has
highlighted to us the importance of gathering
feedback from families and carers as well as
patients. Carers’ views of hospital discharge/
going home from hospital provide a valuable
insight to how these multi-agency processes
can be improved. We would like to see greater
reference to family and carer feedback in all
Quality Accounts in the future.
Catherine Pearson, Healthwatch Lambeth Manager
18/05/2015
50
51
ANNUAL REPORT 2014/2015
Statement from the governors of St
George’s University Hospitals NHS
Foundation Trust
My governor colleagues and I feel the report is
well written with clear presentation, and we are
broadly supportive of the trust’s priorities for
improvement in the coming year. We are pleased
to see that progress has been made on the action
plan that was implemented following the CQC
report. However, there are some areas of concern
that are repeatedly reported at board meetings
where governors are assured that action has been
taken, so it’s disappointing to see some of these
appearing in the Quality Account.
•Meeting London Quality Standards: Adult
acute medicine and adult emergency surgery
still require improvement with standards far
from being fully met, more so in surgery than
in medicine. This poor performance was also
picked up by the CQC in their inspection. These
acute pathways make up a large percentage of
inpatient work at St George’s. It’s important that
the trust focuses on its everyday clinical work as
well as its specialist areas.
•Complaints: The stated standard response rate
to patient complaints has been on the board
agenda regularly but there appears to be little
improvement in this area.
•Research: Research is incredibly important with
its link to improving patient care and treatments.
However, the needs of the research team should
not override the needs of the patient.
•Never events: The report outlines three never
events in obstetrics concerning retained swabs
during the last year. It seems that very little
learning has taken place from RCA in these
instances. At a recent board it was reported that
senior clinicians were continuing to review the
situation so it is disappointing that it has not
improved and the error keeps occurring.
•We welcome the steps being taken to improve
the staff ratings around bullying, harassment and
discrimination and hope this is reflected in the
next staff survey results.
Kathryn Harrison, Lead Governor
21/05/2015
QUALITY ACCOUNT
52
Independent auditor’s limited
assurance report to the Council of
Governors and Board of Directors
of St George’s University Hospitals
NHS Foundation Trust on the
Quality Report
We have been engaged by the Board of Directors
and Council of Governors of St George’s University
Hospitals NHS Foundation Trust to perform an
independent limited assurance engagement in
respect of St George’s University Hospitals NHS
Foundation Trust’s Quality Report for the year
ended 31 March 2015 (the ‘Quality Report’) and
certain performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2015
subject to limited assurance consist of the national
priority indicators as mandated by Monitor:
•Percentage of incomplete pathways within 18
weeks for patients on incomplete pathways at the
end of the reporting period
•Emergency re-admissions within 28 days of
discharge from hospital
We refer to these national priority indicators
collectively as the ‘indicators’.
Respective responsibilities of the directors
and auditor
The directors are responsible for the content and
the preparation of the Quality Report in accordance
with the criteria set out in the ‘NHS Foundation
Trust Annual Reporting Manual’ issued by Monitor.
Our responsibility is to form a conclusion, based
on limited assurance procedures, on whether
anything has come to our attention that causes us
to believe that:
•the Quality Report is not prepared in all material
respects in line with the criteria set out in the ‘NHS
Foundation Trust Annual Reporting Manual’
•the Quality Report is not consistent in all material
respects with the sources specified in Monitor’s
‘Detailed guidance for external assurance on
quality reports 2014/15’, and
•the indicators in the Quality Report identified
as having been the subject of limited assurance
in the Quality Report are not reasonably stated
in all material respects in accordance with the
‘NHS Foundation Trust Annual Reporting Manual’
and the six dimensions of data quality set out in
the ‘Detailed guidance for external assurance on
quality reports 2014/15’.
We read the Quality Report and consider whether
it addresses the content requirements of the
‘NHS Foundation Trust Annual Reporting Manual’,
and consider the implications for our report if we
become aware of any material omissions. We read the other information contained in
the Quality Report and consider whether it is
materially inconsistent with:
•Board minutes for the period 1 April 2014 to 28
May 2015
•papers relating to quality reported to the board
over the period 1 April 2014 to 28 May 2015
•feedback from Commissioners, dated 21/05/2015
•feedback from Governors, dated 21/05/2015
•feedback from local Healthwatch organisations,
dated 18/05/2015
•feedback from Overview and Scrutiny Committee,
dated 18/05/2015
•the Trust’s complaints report published under
regulation 18 of the Local Authority Social Services
and NHS Complaints Regulations 2009, dated
August 2014
•the national patient survey, dated 21/05/2015
•the national staff survey, dated 24/02/2015
•Care Quality Commission Intelligent Monitoring
Report, dated December 2014
53
ANNUAL REPORT 2014/2015
•the head of internal audit’s annual opinion
over the trust’s control environment, dated
26 May 2015
We consider the implications for our report if we
become aware of any apparent misstatements or
material inconsistencies with those documents
(collectively, the ‘documents’). Our responsibilities
do not extend to any other information.
We are in compliance with the applicable
independence and competency requirements of
the Institute of Chartered Accountants in England
and Wales (ICAEW) Code of Ethics. Our team
comprised assurance practitioners and relevant
subject matter experts.
This report, including the conclusion, has been
prepared solely for the Council of Governors of
St George’s University Hospitals NHS Foundation
Trust as a body and the Board of Directors of the
Trust as a body, to assist the Board of Directors
and Council of Governors in reporting St George’s
University Hospitals NHS Foundation Trust’s quality
agenda, performance and activities. We permit the
disclosure of this report within the Annual Report
for the year ended 31 March 2015, to enable the
Board of Directors and Council of Governors to
demonstrate they have discharged their governance
responsibilities by commissioning an independent
assurance report in connection with the indicators.
To the fullest extent permitted by law, we do not
accept or assume responsibility to anyone other
than the Board of Directors as a body, the Council
of Governors as a body and St George’s University
Hospitals NHS Foundation Trust for our work or this
report, except where terms are expressly agreed
and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement
in accordance with International Standard on
Assurance Engagements 3000 (Revised) –
‘Assurance Engagements other than Audits or
Reviews of Historical Financial Information’,
issued by the International Auditing and Assurance
Standards Board (‘ISAE 3000’). Our limited
assurance procedures included:
•evaluating the design and implementation of the
key processes and controls for managing and
reporting the indicators
•making enquiries of management
•analytical procedures
•limited testing, on a selective basis, of the data
used to calculate the indicator back to supporting
documentation
•comparing the content requirements of the ‘NHS
Foundation Trust Annual Reporting Manual’ to the
categories reported in the quality report and
•reading the documents.
A limited assurance engagement is smaller in
scope than a reasonable assurance engagement.
The nature, timing and extent of procedures
for gathering sufficient appropriate evidence
are deliberately limited relative to a reasonable
assurance engagement.
Limitations
Non-financial performance information is
subject to more inherent limitations than
financial information, given the characteristics
of the subject matter and the methods used for
determining such information.
The absence of a significant body of established
practice on which to draw allows for the selection
of different, but acceptable measurement
techniques which can result in materially different
measurements and can affect comparability. The
precision of different measurement techniques may
also vary. Furthermore, the nature and methods
used to determine such information, as well as the
measurement criteria and the precision of these
criteria, may change over time. It is important
to read the Quality Report in the context of the
criteria set out in the ‘NHS Foundation Trust Annual
Reporting Manual’.
The scope of our assurance work has not included
governance over quality or non-mandated indicators,
which have been determined locally by St George’s
University Hospitals NHS Foundation Trust.
Conclusion
Based on the results of our procedures, nothing
has come to our attention that causes us to
believe that, for the year ended 31 March 2015:
•the Quality Report is not prepared in all material
respects in line with the criteria set out in the ‘NHS
Foundation Trust Annual Reporting Manual’;
•the Quality Report is not consistent in all material
respects with the sources specified above; and
•the indicators in the Quality Report subject to
limited assurance have not been reasonably stated
in all material respects in accordance with the
‘NHS Foundation Trust Annual Reporting Manual’.
Grant Thornton UK LLP
Grant Thornton House
Melton Street
Euston Square
LONDON
NW1 2EP
28 May 2015
QUALITY ACCOUNT
54
Annex 2: Statement of directors’
responsibilities for the quality report
The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts)
Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality
reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation
trust boards should put in place to support the data quality for the preparation of the quality report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:
•the content of the quality report meets the requirements set out in the NHS Foundation Trust Annual
Reporting Manual 2014/15 and supporting guidance
•the content of the Quality Report is not inconsistent with internal and external sources of information
including:
- board minutes and papers for the period April 2014 to April 2015 papers relating to quality reported
to the board over the period April 2014 to April 2105
- feedback from commissioners dated 25/05/2015
- feedback from governors dated 21/05/2015
- feedback from local Healthwatch organisations dated 18/05/2015
- feedback from Overview and Scrutiny Committee dated 18/05/2015
- the trust’s complaints report published under regulation 18 of the Local Authority Social Services and
NHS Complaints Regulations 2009, dated 01/04/2014
- the latest national patient survey dated 08/05/2015
- the latest national staff survey dated 24/02/2015
- the head of internal audit’s annual opinion over the trust’s control environment dated 26/05/2015
- CQC Intelligent Monitoring Report December 2014
•the quality report presents a balanced picture of the trust’s performance over the period covered
•the performance information reported in the Quality Report is reliable and accurate
•there are proper internal controls over the collection and reporting of the measures of performance
included in the quality report, and these controls are subject to review to confirm that they are working
effectively in practice
•the data underpinning the measures of performance reported in the Quality Account is robust
and reliable, conforms to specified data quality standards and prescribed definitions, is subject to
appropriate scrutiny and review and
•the quality report has been prepared in accordance with Monitor’s annual reporting guidelines (which
incorporates the quality accounts regulations) as well as the standards to support data quality for the
preparation of the quality report.
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the quality report.
By order of the board
Chairman:
Chief Executive:
55
ANNUAL REPORT 2014/2015
Appendices
Appendix A: Participation in national clinical audits and national confidential enquiries
The national clinical audits and national confidential enquires that St George’s University Hospitals NHS
Foundation Trust participated in, and for which data collection was completed during 2014/15, are listed
below alongside the number of cases submitted to each audit or enquiry as a percentage of the number
of registered cases required by the terms of that audit or enquiry.
RELEVANT
PARTICIPATING SUBMISSION RATE (%) / COMMENT
ACUTE
National confidential enquiry into patient
outcome and death
Sepsis: Currently 80%, data
submission deadline 30th April 2015
ü
ü
Gastrointestinal haemorrhage: 100%
ü
ü
ü
ü
ü
ü
Ongoing: deadline for data entry is
31st May 2015
Lower limb amputation: 71%
Tracheostomy care: 92%
Adult community acquired pneumonia
ICNARC case mix programme
National emergency laparotomy audit
National joint registry
Pleural procedure
Severe trauma (Trauma Audit & Research
Network – TARN)
ü
ü
ü
ü
ü
ü
Ongoing
2014 data – 19.4%.
2015 – ongoing
Ongoing
50%
Ongoing
BLOOD & TRANSPLANT
National comparative audit of blood transfusion
Audit of patient information and
consent: 100%
ü
ü
ü
ü
ü
ü
Ongoing
ü
ü
ü
ü
ü
ü
Ongoing, data entry for 2014 is open
until 29th May 2015.
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
Ongoing, data entry deadline 31st May
2015
Audit of transfusion in children and
adults with sickle cell disease: 100%
CANCER
Bowel cancer
Head and neck oncology (DAHNO)
Lung cancer (NLCA)
Oesophago-gastric cancer (NAOGC)
Prostate cancer
Ongoing (national data entry system
not currently available)
Ongoing
Ongoing
HEART
Acute coronary syndrome or Acute
myocardial infarction (MINAP)
Congenital heart disease
Cardiac rhythm management
Coronary angioplasty (PCI)
National adult cardiac surgery audit
National cardiac arrest audit
National heart failure audit
Ongoing
Ongoing, data entry deadline 30th June
2015
100%
Ongoing, data entry deadline 30th June
2015
Ongoing
Ongoing, data entry deadline 1st June
2015
Carotid intervention: Ongoing
National vascular registry
ü
ü
AAA: Ongoing
Peripheral arterial disease: Ongoing
QUALITY ACCOUNT
56
LONG TERM CONDITIONS
Core diabetes audit – Began collecting
data in January 2015. Data collection is
ongoing
Diabetes (Adult)
ü
ü
Diabetes care in pregnancy: 100%
Diabetes (Paediatric) (NPDA)
ü
ü
ü
ü
100%
Inflammatory bowel disease (IBD)
Diabetes foot care – deadline 31st July
2015. We have not participated to
date but intend to begin submissions
in 2015/16
Ongoing, data collection September 14
to February 16
Organisational: 100%
Secondary: 64.8%
Pulmonary rehab: Ongoing, deadline
for data entry is 10th July 2015
National chronic obstructive pulmonary
disease (COPD) audit programme
ü
ü
Renal replacement therapy (Renal registry)
ü
ü
ü
ü
Ongoing
ü
ü
96%
ü
ü
ü
ü
ü
ü
Ongoing
ü
ü
Ongoing
Rheumatoid and early inflammatory arthritis
Ongoing, data entry for 2014 is open
until 30th April 2015.
MENTAL HEALTH
Mental health care in the emergency
department
OLDER PEOPLE
Falls and Fragility Fractures Audit
Programme National Hip Fracture database
Older people (care in emergency departments)
Sentinel stroke national audit programme
(SSNAP)
100%
Ongoing
OTHER
Elective surgery (National PROMS Programme)
National audit of intermediate care
ü
ü
Organisational: 100%
Patient surveys: Number per
organisation not reported
Adherence to British Society for Clinical
Neurophysiology (BSCN) and Association of
Neurophysiological Scientists (ANS) standards
for ulnar neuropathy at elbow (UNE) testing
ü
û
We did not participate due to extended
clinics and insufficient staff to
complete the audit
ü
ü
ü
ü
100%
ü
ü
ü
ü
ü
ü
Ongoing
WOMEN’S & CHILDREN’S HEALTH
Epilepsy 12 audit (Childhood epilepsy)
Fitting child (care in emergency
departments)
Maternal, newborn and infant clinical
outcome review programme (MBRRACE-UK)
Neonatal intensive and special care
Paediatric intensive care (PICANet)
100%
Ongoing
Ongoing
57
ANNUAL REPORT 2014/2015
Appendix B: National clinical audit actions undertaken
The reports of 10 national clinical audits were reviewed by the provider in 2014/15 and St George’s
University Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of
healthcare provided.
NATIONAL CLINICAL AUDIT ACTION*
National diabetes inpatient Overall 82% reported that they were satisfied or very satisfied with the overall care of their
audit
diabetes whilst in hospital. The main areas for improvement appear to be in the timing and
suitability of meals and staff knowledge of diabetes. Action is underway to tackle these
problems and funding from an external source is being used to finance a part time Band 6
nurse to conduct a project looking at the development of an inpatient diabetes team.
National head and neck
cancer audit 2013 – ninth
annual report (2014)
Action plan:
•Explore the re-instatement of the RMH CNS )cancer nurse specialist) in the head and
neck clinic to support those patients going for primary RT/Chemo-RT
•All grades of medical staff when they start should be informed of the ideal pathway and
who to involve
•CNS, (and dietetic and SALT), contact numbers are displayed in all clinic rooms in ENT
and Maxillofacialto remind doctors to refer patients and provide ease of referral
•CNS to see patients when they are told the cancer diagnosis from FNA even if primary
tumour has not been identified at that time
•Letter with CNS information to be given to patients who come to the clinic for diagnosis
but not able to see the CNS.
National cardiac arrest
audit 2013/14
Action plan:
•Closely monitor the numbers of emergency calls and determine what proportion are
cardiac arrests and which are peri arrest (patient medical emergencies)
•Identify any unusual trends in activity and report this back to individual care groups to
investigate
•Analyse cardiac arrest data monthly to look at the number of calls and survival,
comparing these to previous months
•Resuscitation training for all qualified nurses includes recognition and management of
the deteriorating patient in an attempt to prevent cardiac arrest
•Recently standardised all the defibrillators at St George’s Hospital to a single model
from four separate models
•Ensure that emergency resuscitation equipment is readily available or accessible in all
areas of the trust.
Sentinel stroke national
audit programme (SSNAP)
Action Plan:
The plan is multifaceted and requires engagement and support from other services within
the trust, commissioners, ambulance services and local trusts. Some of the key actions
include
•Identified metrics to present to board as part of ongoing performance monitoring to
raise awareness and suggest quarterly reporting in line with audit publication
•Monthly data review by the clinical team at stroke care group
•Monthly senior management meeting on stroke performance
•Dedicated clinical time to validate data
•A new clinical proforma
•Consultant doubling-up on the HASU (hyper acute stroke unit)
•Seven day therapy is now up and running.
Planned improvements for the coming year include improved MRI access, increased TIA
clinic activity and embedding extra consultant cover on the SU.
UK irritable bowel
disease audit
At the time of this audit we did not have a paediatric IBD specialist nurse in post. This role
was recruited to in February 2014 and now all paediatric inpatients are reviewed by an IBD
nurse specialist.
QUALITY ACCOUNT
College of emergency
medicine sepsis audit
2013
58
Medical and nursing teaching sessions held to address:
•Improving completeness of documentation of initial observations
•Prescribing oxygen
•Completion of audit form in notes
•Prescription of fluids.
Regular project meetings to ensure progress and delivery of the above actions.
British thoracic society
(BTS) paediatric
bronchiectasis report
2013/14
Since the appointment of the paediatric respiratory consultant the trust has contributed
1.5 WTE paediatric physiotherapists to the team to increase time available for respiratory
physiotherapy and offer some cover for regional work. We now have a nominal lead for
paediatric respiratory physiotherapy.
From December 2014 we started a monthly bronchiectasis clinic as part of the respiratory
clinic. For these clinics we are expecting the physiotherapist to be available to see children
alongside the physician. It is anticipated that the development of a regular clinic will
ensure a consistent approach to the performance of routine investigations.
National hip fracture
database (NHFD) report
2014
Business cases have been prepared in order to increase consultant numbers. This will
support improved discharge planning, facilitating quicker admission to the orthopaedic
ward. Another business case has been developed to accommodate additional trauma
capacity, thereby reducing delays between admission and surgery.
It is expected that an additional ortho-geriatrician will be in post from March 2015. This
role will impact on a number of standards, including senior review within 72 hours of
admission and medication assessment. Three additional physician assistant posts have
also been introduced which through a shared workload will enable improvement in a
number of standards such as bone health assessment and conducting the abbreviated
mental test. Recruitment of a dedicated trauma co-ordinator who will be responsible for
co-ordinating the collation and completion of the trust’s NHFD data will ensure robust data
entry and an accurate reflection of our service.
Epilepsy 12 round 2
Action plan:
•Audit results have been presented to all specialties and disciplines involved in the care
of paediatric epilepsy patients for discussion, recommendations and action planning.
•Changes to the waiting area have been made.
•Explore the context and issues around staff not working well together.
•Amend the epilepsy proforma to include a ‘water safety’ tick box.
Clinical audit of COPD
exacerbations to acute
units
Recommendations for access to specialist care has been partially addressed as, subject
to provision of appropriate junior support the respiratory team will move to seven day
working.
*Based on information available at the time of publication
59
ANNUAL REPORT 2014/2015
Appendix C: Local clinical audit actions undertaken
The reports of five local clinical audits were reviewed by the provider in 2014/15 and St George’s
University Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of
healthcare provided.
LOCAL CLINICAL AUDIT
ACTION*
National early warning
score (nEWS) audit
Actions are ongoing with continued education for registered nurses on Harm Free Care
days (which are being expanded and strengthened further), nurse induction and other
EWS training events. General ICU provides a three hour training session for healthcare
assistants bi-monthly and EWS assessment is included as a part of the Band 5
assessment centre. It should be noted that electronic documentation has commenced in
some areas and this will support accurate calculation of the warning score. Six-monthly
re-audit was included in the annual programme for 2014/15.
Venous access device
care audit
There was an improvement in four of the six standards compared to the 2013 audit. Poorly
performing areas have been provided with their results and asked to submit action plans
addressing local issues to the Venous access service and Infection control team. Ward
staff will be supported through increased education provided by both of these teams,
particularly in areas where attendance at FRED training has been low. All wards have also
been asked to consider the use of tubi-grip instead of bandages. Re-audit will assess the
impact of these changes. It is planned that the frequency of audit will increase to sixmonthly and that performance across all areas of the trust will be measured.
Protected mealtimes audit
All ward areas have to ensure that they challenge and escalate non-clinically urgent
interruptions, as appropriate. In addition wards that did not display information for staff,
patients and visitors regarding protected mealtimes are required to display the corporate
poster. Sisters and matrons, in liaison with dietitians have been asked to review nutritional
screening practice and standards. Six-monthly re-audit included in the annual programme.
WHO surgical checklist
audit Q3 2014/15
Action Plan:
•Present findings at theatre care group and divisional governance board meetings.
•MD to discuss with clinical directors and care group leads and request action plans for
those specialties which are non-compliant.
•Theatre matrons and team leaders to ensure there is discussion at local team meetings
and an action plan for areas of non-compliance.
•Theatre staff to report as adverse incident if checks are not completed.
Audit of type I education
course (beta cell education
resources for training in
insulin and eating: BERTIE)
at Queen Mary’s Hospital
To explore other methods/times of presenting the BERTIE course or of providing education
in smaller more manageable chunks by liaising with staff at other trusts to obtain details
of the courses they offer and the rate of uptake they experience. If there is anything they
are doing differently that increases attendance rate then we will consider a changed
timeframe for BERTIE (e.g. evenings/Saturdays).
To provide GPs with a new referral template and to re-audit to assess if this is used.
QUALITY ACCOUNT
60
Appendix D: Further details of the agreed CQUIN goals for 2014/15
Quarter 4 and final year end CQUIN (Commissioning for Quality and Innovation) performance and
achievement is currently being reviewed and finalised with commissioners. The Trust forecasts CQUIN
performance delivery of 90 per cent for 2014/15.
CQUIN goals and indicators
Achievement
Comments
National CQUINs
Friends & family test
– Implementation of FFT to outpatients and daycase services
– Increased response rates
– Improved performance on the Staff Friends and Family Test
NHS safety thermometer
– Reduction in the prevalence of pressure ulcers acquired by
patients in the trust, measuring reduction in grades 2&3 for
pressure ulcers using national safety thermometer as the
measure.
– Audit 3 nursing homes and development improvement plans
Dementia
– Find, assess, investigate and refer
– Clinical leadership
– Supporting carers of people with dementia
Fully met
Partially met
Audit undertaken and action plan
developed. Training package also
developed and delivered to nursing
homes staff.
Reduction target of no more than 40
grade 3+ pressure ulcers not met.
Fully Met
Local CQUINs
End of life
– Establish an ongoing education and training programme
around keyareas of end of life care
– Extension of use of CMC or equivalent and audit use of LCP
Fully met
Smoking cessation – Smokers are supported by being given
advice and sign posted to relevant SSS if interested in quitting.
Fully Met
NIA/PAU consultant cover – To ensure the paediatric
assessment unit has consultant cover for 7days a week,
between 9am and 9pm
Fully Met
Maternity services
– Increase midwifery workforce ratio
– Supernumerary midwife cover on Delivery Suite
– Deliver 144 hours consultant cover
Fully met
GP communication – Continue to improve on the quality and
speed of communication of discharge letters to GPs. Expand
the services involved and work on developments to improve
communication to patients.
Partially met
Care of the elderly – To improve patient care on discharge and
help signpost patients to the correct care without the need for
readmission.
Fully Met
Heart failure – The aim of this indicator is to improve quality of
care, and reduce mortality and morbidity
Fully Met
COPD – (chronic obstructive pulmonary disease)
To improve the COPD pathway.
Fully Met
TB – Improve contacts with positive TB patients, improve
communication with GPs, ensure positive plural TB patients
have a home visit in two weeks and complex TB patient are
better cared for
Fully Met
Medicines management – Implementation of the New Oral
Anticoagulants (NOACs) guidance. Improved reporting of
medication-related safety incidents.
Fully Met
OP and A&E discharge summaries
targets met.
IP discharge summaries target
of 85% electronic delivery to GPs
within 48hrs not met.
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ANNUAL REPORT 2014/2015
End of Life Care – Improve training and awareness of how to
deal with EOLC.
Patients placed on CMC
Fully Met
Community CQUINs
Outcomes framework – Development of an outcomes framework
for the services provided within the new community adult health
service model
Fully Met
Learning Disabilities – Review of the service to support future
redesign
Fully Met
Children’s services – Review of the service to support future
redesign
Fully Met
Information sharing – Developing multi disciplinary teams and
a platform for primary care to access community data
Fully Met
COTE – MDT Team – Developing MDTs to ensure staff are
sharing information and providing advice and support from
people with different skills.
Fully Met
NHS England CQUINs
Dashboards – Ensure providers embed and routinely use the
required clinical dashboards developed during 2013/14 for
specialised services.
Fully Met
Perinatal pathology – To implement a nationally predictable
reporting time of 42 calendar days for 70% if perinatal
autopsies and also adhere to the current specification a total of
90% of all perinatal autopsies issued within 56 days
Not Met
Cardiac surgery – Patients referred as semi urgent to have
coronary artery bypass grafting as an inpatient (with or without
transfer) within 7 days of angiogram. 20% reduction in patients
not being treated within 7 days following baseline received.
Fully Met
Specialised orthopaedics – Complex cases of orthopaedic
surgery (mainly revisions) are discussed in a network MDT and
in line with agreed network protocols, to improve outcomes and
reduce infections and revisions.
Fully Met
Tertiary level fetal medicine Opinion within 3 days
Fully Met
Retinopathy in prematurity – Increase in screening of babies
with a birth weight of <1501g or a gestation of <32+0 weeks who
undergo 1st Retinopathy of Prematurity (ROP) screening whilst still
an in-patient and screening 'on time'
Fully Met
Neuro rehab – Patient flow improvement through clinical
utilisation review. Implementation of a real time web-based
waiting list management system
Fully Met
Severe and complex obesity – Review clinical pathway and
tariff
Fully Met
Breast screening – Increase in uptake
Fully Met
Early years – CHIS to CHIS interface and smoking cessation
Fully Met
Offender healthcare – Hepatitis B immunisation – uptake
Offender healthcare – TB screening
Offender healthcare – Staffing – The indicator measures the
level of staffing in post across Offender healthcare services
and aims to reduce instances where offenders cannot access
healthcare due to staffing shortages.
Offender healthcare – Access to mental health
Partially Met
Database and reporting matrix setup and implemented.
Reporting time targets not met.
Implementation plan was developed
and delivered. However, uptake
targets were not met in Q3 and Q4.
Fully Met
Partially Met
Fully Met
All targets were delivered. However,
final staffing establishment
agreement was delayed and
exceeded original deadline of Q2.
QUALITY REPORT
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